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An official of the Philippine Health Insurance Corp. (PhilHealth) claimed it has been robbed of P4 billion in dubious and exorbitant claims on top of another P5 billion in unremitted premium payments.

PhilHealth vice president Madeleine Valera told a Senate hearing yesterday that medical practitioners have been making dubious claims from Philhealth.

Valera made the disclosure to Sen. Richard Gordon during a hearing called over reports that some hospitals have threatened to go on a holiday in protest over the implementation of the Hospital Detention Law.

Valera said PhilHealth has recorded a total of P4 billion in losses since 1995 because of the claims by physicians and hospitals for “irrational” procedures and bloated prices of medicines.

She also revealed that government has not paid P5 billion in premiums for cardholders since 2001, making the government the top violator in terms of remitting premiums.

According to Valera, doctors and certain hospitals took advantage of their patients by claiming their own benefits and privileges from PhilHealth after being operated on or having been checked up.

She said some hospitals even had “ghost patients” while some surgeons were performing unnecessary operations.

In one instance, Valera said a surgeon earned P17 million in a year by performing at least 2,000 cataract and other eye operations.

She explained a doctor could claim P12,000 to P16,000 per eye in every operation or P24,000 to P32,000 for both eyes.

Valera said the doctor could report having performed at least two operations on a patient and could claim P64,000 from PhilHealth.

Valera said the physicians could also add some provisions in their reimbursements and manufacture claims by asking patients to sign blank documents even just for consultations and minor procedures.

“The patients won’t know afterwards what the doctors and hospitals are claiming on their behalf,” she said.

Valera added doctors and hospitals could likewise prescribe expensive medicines and earn from them.

“Because of our old system, we got to pay these claims. It is difficult to prevent sophisticated fraudulent acts by my colleagues, the doctors,” Valera said.

Valera stressed the illegal claims made a big impact on the financial state of the institution.

“For those who need surgical procedures, if they are not qualified to be insured at first, they would wait for, let’s say, three months and after they qualify, then that is the only time they will perform the operation,” Valera explained.

Valera said they had sought help from different medical societies and hospital associations in the effort to stop the illegal practices.

“Any act or service provided (to a patient), we have to pay,” she said.

Valera said even in toe nail extraction or circumcision, doctors could claim P4,000 to P5,000 and PhilHealth had recorded increased claims for such cases.

“There are irrational, unnecessary (procedures) but why did they do it? It is a medical malady, systematic disease, a systemic failure, or medical cancer,” she said.

The hearing was called supposedly to determine how PhilHealth could be utilized to make every Filipino capable of paying his hospital bills.

Gordon said Congress would have to look into these malpractices.

Gordon and Sen. Juan Ponce Enrile said they could not comprehend why hospitals were quick to threaten a strike amid the mounting complaints of padding claims and other malpractices.