COA flags PhilHealth over database mess

CEBU, Philippines — The Commission on Audit (COA) has called out the Philippine Health Insurance Corporation (PhilHealth) over the erroneous database of senior citizens resulting in overpayment of subsidies due to multiple enrollments, duplication of entries and inclusion of 4,062 deceased members.

“The process controls in the membership data collection and management of 8,586,271 enrolled Senior Citizens (SCs) were deficient...thus exposing the Corporation to the risk of generating inaccurate or unreliable data and possible payment of fraudulent claims,” the COA said in its 2023 annual audit report on PhilHealth.

The COA noted that of the total senior citizens enrolled in PhilHealth's Members Information System (MIS), 15 percent or 1,335,274 have “incomplete and erroneous” data entries such members without middle names, members with last names only bearing a single letter and several “other irregularities and errors”.

State auditors said this situation “increases the risk of double or multiple entries per member since the matching validation is programmed to detect only an absolute match of entries contained in the database.”

In fact, the COA said, its audit team had already detected duplication and multiple entries for 266,665 enrolled senior citizen members equivalent to P1.333 billion in subsidy.

“It bears stressing that the duplicate or multiple entries in the PhilHealth Membership Database (PMD), not only overstate the billing of premiums to the national government (NG) through the Department of Budget and Management (DBM) but may also mislead [PhilHealth] Management and the public as to the actual number of beneficiaries already covered in the National Health Insurance Program (NHIP), as well as the measurement of PhilHealth’s actual performance and accomplishment thereof,” the COA said.

Deceased members

Furthermore, the COA said the audit also discovered the inclusion of a total of 4,062 deceased senior citizens in the PMD with the corresponding billings to the DBM for 2023.

The COA said the number was culled through verification with various healthcare institutions (HCIs), which have earlier tagged the senior citizen members as deceased in 2019 to 2022, but were still not tagged as “active” or “inactive” instead of “deceased in the PMD.

The COA said this was despite PhilHealth's existing Memorandum of Agreement (MOA) with the Philippine Statistics Authority (PSA) signed on June 19, 2021 on data sharing of death information records.

“[The] non-updating of the status of 4,062 deceased SC members in the database has led to over subsidy from the NG totaling P18.080 million, pertaining to the 3,616 deceased members as at CY 2022, which could have been used and attributed by the NG to other important and vital government projects, and exposes PhilHealth to risk of generating inaccurate/unreliable data and possible payment of fraudulent claims,” the COA said.

In reply incorporated in the audit report, the PhilHealth said it had already obtained from the PSA the data of a total of 5,422,197 members with death information, of which, 661,533 were already updated in the PMD.

PhilHealth added that it had already requested from the audit team the list of deceased senior citizen (SC) members noted in the audit report “for proper validation”.

“The Audit Team commended [PhilHealth] Management for the significant efforts exerted in the updating of the PhilHealth database, as well as its proper coordination with the PSA. Nonetheless, the completion of the updating of PMD will be monitored in the succeeding audit,” the COA said in a rejoinder.- —/FPL (FREEMAN)