June 11, 2019
GHOSTS aren’t real. Or so they say. In the latest of a string of controversies plaguing the Philippine Health Insurance Corp. (PhilHealth), recent reports have attributed the loss of billions of pesos of people’s money to “ghost” patients.
According to whistleblowers Edwin Roberto and Liezel Santos, former employees of the privately run WellMed Dialysis Center and Laboratory Corp., the scheme involved PhilHealth funds being claimed and released for the dialysis treatment of dead patients. Yup, that’s right.
Apparently, ghosts can get sick (and have to be treated!). The issue has thrust PhilHealth back into the national spotlight, albeit for all the wrong reasons. The timing is especially worrisome, considering that PhilHealth itself is the agency tasked with the implementation of the recently passed Universal Health Care Act (UHC Act). Understandably, the scandal has cast serious doubt on the agency — how will it be able to effectively implement such a complex and extensive law like the UHC if it can’t even efficiently monitor its current system? The answer seems to be that it can’t, at least for now.
As a result of the scandal, President Rodrigo Duterte is looking into reorganizing and reshuffling the entire agency. The President wondered how funds could be dispersed so easily without any (supposed) system of checks and balances, and without any kind of accountability whatsoever. He’s right. How could it?
Section 46 of the implementing rules and regulations of Republic Act 7875 the “National Health Insurance Act” provides for the time period within hospitals or clinics may file reimbursements or claims for payment of services rendered although this may be extended by PhilHealth. It is healthcare providers (i.e. hospitals or clinics) which should “submit the prescribed and completely filled- up PhilHealth claim forms and other documents required for processing.
This system of self-reporting, along with the extended period to file claims, opens the claims process to abuse. Whistleblower Edwin Roberto revealed that the scheme is centered around Philhealth’s dependence on the reporting by hospitals or clinics of the deaths of their patients. Roberto said that “[i]f a patient died at home, dead on arrival, or died in the hospital within 24 hours, there is no need to submit any document to PhilHealth to update and make claims. Because Philhealth is unable to know if a patient has died, the facility continues to charge and file claims.”
In simple terms, if PhilHealth does not know that a patient is already dead, it will keep on paying for these ghost treatments. Not only that. Other fraudulent schemes have continued to run roughshod on PhilHealth’s operations. Some of these schemes involve the “padding” of expenses to make it appear that the hospital or clinic incurred more than what was actually spent.
Another is the claiming of unused benefits. For example, a dialysis patient who only used up 40 of the 90 sessions he or she is entitled to under the rules, opens up the remaining 50 (that is, the unused sessions) to manipulation. If you put yourself in the shoes of the patient, would you really care about the remaining 50 sessions, if 40 sessions is all you actually need? In case the patient will not use up all of his or her entitled benefits, the remaining sessions may be fraudulently claimed by the health care provider for their own benefit.
No law or process is perfect. But as constructed at present, the PhilHealth rules and processes leave a lot to be desired. The problem was actually recognized in the UHC Act, Section 4 (u) of which states that “[u]nethical acts refers to any action, scheme, or ploy against the NHIP such as overbilling, upcasing, harboring ghost patients…” Principally authored by outgoing Sen. “JV” Ejercito, the law aims to “[e]nsure that all Filipinos are guaranteed equitable access to quality and affordable health care goods and services, and protected against financial risk.” Undeniably, the implementation and success of the law will be heavily dependent on whether PhilHealth gets its act together.
A lot of PhilHealth’s funding comes from enforced contributions. And they will burden the public into compliance for billions of funds to…go missing? To be used to treat ghosts? This means billions of funds wasted that could have been put to better use. This is money that could have been used to fund people who are actually sick, and not the ghosts that roam the halls of PhilHealth and its accredited hospitals or clinics.
Aside from going after the perpetrators of the scam (which by all means, we should do), we must be proactive and focus on the upcoming UHC Act, which will place a bigger administrative and financial burden on PhilHealth. Immediately, that focus should be geared towards improving the provisions of the implementing rules and regulations of the UHC Act.
Legislators should take a cue from the recent controversy to carefully design preventive mechanisms for the better implementation of the UHC Act. This requires revisiting the allocation of the 7.5 percent administrative cost for implementing the program. An improved reporting process, as well as a system of review to check the veracity of claims, will go a long way toward minimizing the misuse of funds.
As the President said, a system of checks and balances must not only be instituted, but strictly followed. Stiffer penalties should be considered. After all, these are public funds we are dealing with, and any misuse of public funds should be accounted for.
The UHC Act itself is groundbreaking legislation — the first of its kind in the Western Pacific region. Despite its laudable objectives, and the hard work put in by our legislators, it runs the risk of being mishandled and upended by the few who value their quality of life over the health of their fellow Filipinos. Oh! The irony.
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