Guevarra says DOJ and NBI to probe PhilHealth insurance ‘upcasing’ fraud

Justice Secretary Menardo Guevarra

JUSTICE Secretary Menardo Guevarra on Thursday assured the Philippine Health Insurance Corp. (PhilHealth) that the Department of Justice (DOJ) and the National Bureau of Investigation  (NBI) are willing to help the state-run health insurer in investigating fresh reports of alleged “upcasing” of minor respiratory ailments to Covid-19  for higher insurance claims.

Guevarra issued the assurance following PhilHealth’s statement that it would probe deeper into video posts indicating the resurgence of upcasing schemes wherein health-care providers allegedly collude with patients to declare minor respiratory symptoms such as asthma as Covid-19 to claim higher benefits.

“The DOJ-led Task Force PhilHealth conducted a thorough investigation of upcasing schemes last year and cases were filed thereafter. PhilHealth is currently looking into new incidents of  upcasing  in relation to Covid claims,” Guevarra stated.

“With a former NBI chief as president/CEO [Chief Executive Officer], PhilHealth can very well handle this new investigation, but the DOJ [and] NBI will be ready to provide assistance if requested,” the justice secretary assured.

Last year, the Task Force PhilHealth had previously recommended the filing of criminal and administrative charges against seven officials of the agency for violation of Anti-Graft and Corrupt Practices Act for their alleged involvement in the multibillion PhilHealth fund embezzlement.

The task force had wrapped up its investigation on reported anomalies in PhilHealth, but its composite teams are still continuing with the investigations to determine the liability of others involved in similar or other wrongful practices in the agency.

Early this year, the task force endorsed the report submitted by the Presidential Anti-Corruption Commission  (PACC) to the Office of the Ombudsman recommending the filing of criminal and administrative charges against 25 incumbent and former officials of PhilHealth Regional Office 1.

The said 25 individuals are now facing charges of  (i) Falsification by Public Officer under Article 171 of the Revised Penal Code (RPC); (ii) Malversation under Article 217 of the RPC, (iii) Usurpation of authority under Article 177 of the RPC; (iv) Violations of the Anti-Graft and Corrupt Practices Act under Republic Act (RA) 3019; (v ) Violations of the National Health Insurance Act of 1995 under RA 7875, as amended by RA 9241 and 10606; and (vi) administrative liabilities for Grave  Misconduct and Conduct Prejudicial to the Best Interest of the Service.

As a form of health-insurance fraud, upcasing refers to claiming for a related illness or procedure of higher severity or complexity to gain higher benefit payment.

Those found guilty may be fined P200,000 for each count, or suspension of contract up to three years of the health-care provider, or both.

It also constitutes a criminal violation punishable by imprisonment for six months and one day up to six years upon the discretion of the court in accordance to Section 38 of the Universal Health Care Law.

The PhilHealth, headed by former NBI chief Dante Gierran, vowed to look into the veracity of the video posts.

It also asked those who posted the videos to cooperate with the investigation by providing proof that would support the filing of criminal cases for those who may be involved.

At the same time, it also warned the public against posting information without any proof to support their claims, especially at this time of the Covid-19 pandemic as this is tantamount to cyber libel and violation of Article 154 of the Revised Penal Code criminalizing publication of false information that may endanger the public order or cause damage to the interest or credit of the State.

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