Systems in place to detect bogus hospital claims – PhilHealth

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THE Philippine Health Insurance Corporation or PhilHealth has assured their members that “systems” are in place to identify fraudulent acts of some hospitals and wellness centers, in light of the “ghost dialysis” scam.

Dr. Shirley Domingo, PhilHealth spokesperson, said their systems have safeguards that can detect some hospitals’ fraudulent acts.

“‘Yung system(s) namin nakaka-detect na yan ng mga ganyan, marami rin kasi overlapping claims, double-filing ng claims. Yun ang maraming insidente sa amin. So yung aming system nakaka-detect na yon ng mga ibang fraudulent cases,” she said.

Domingo cited one red flag is when small hospitals try to ask for claims that are higher than those sought by third-level hospitals.

She said these dubious claims were detected through PhilHealth’s machine learning identification system.

The spokesperson further said that PhilHealth’s Claim Form 4 also helps detect potential fraud as it asks requesting hospitals for more details on their claims.

Earlier, the PhilHealth suspended 38 erring officials and employees as it pressed the fight against fraudulent and corrupt activities.

Domingo previously said WellMed Dialysis & Laboratory Center Corp’s applying for claims over “ghost dialysis” is not an isolated case because the agency has been investigating more than 8,000 cases of fraudulent acts ranging from ghost patients, false claims, and misrepresentation of patients.

“Itong 2016 na nangyari na ito ay nasumbong sa amin ito last year. So iniimbestigahan na agad din namin yon. Mayroon tayong mga automated systems, database na makaka-identify na ng fraud na dating nakakalusot, ngayon hindi na po makakalusot,” she disclosed.

PhilHealth officials confirmed that they were able to monitor fraudulent acts involving WellMed. Their findings showed that 28 of the medical cases that have been filed involved dead patients.

Domingo said it cost roughly around P70,000 to P80,000. Twelve other cases are still under investigation.

Meanhile, Dr. Rusty Jimenez, President of the Private Hospitals Association of the Philippines, confirmed that fraudulent claims were indeed made by private hospitals, but the cases were minimal.

“Very minimal yan if ever... Hindi natin dine-deny na may nagsasamantala,” he said.

Jimenez, however, also pointed out that in some instances, the “fraudulent acts” allegedly committed by hospitals were really clerical errors made by PhilHealth.

“Pinalalabas ng PhilHealth na lahat ng kasalanan nasa private hospitals. Hindi po totoo lahat yan. Before iniisa-isa na nila yung claim. So inalis nila yung trabaho sa kanila, sinabi nila lahat na lang, isang case na lang, isa na lang ang bayad na hindi na iche-check ang bawat details,” he said.

Jimenez heaped the blame on PhilHealth’s “disorderly” system on the delay of transmission of their requests.

“‘Pag malabo yung request, ibabalik na naman nila sa ospital sasabihin nila mali yung claim ng hospital. So ngayon ang dinadahilan nila palagi, fraudulent claim. Minsan clerical error lang po eh ipababalik na naman sa private hospital so nade-delay na naman ng 60 days, kasi they’re allowed to pay in 60 days,” he said.

Jimenez also claimed that PhilHealth is appointing personnel who have no prior work experience in hospitals.