PhilHealth stops paying 2 hospitals over alleged pneumonia fraud

MANILA, Philippines - The Philippine Health Insurance Corp. (PhilHealth) has stopped paying two private hospitals, one in Northern Luzon and another in Mindanao, over an alleged pneumonia fraud.

Minguita Padilla, head executive staff of the health secretary and chair of the Eye Bank Foundation of the Philippines, said that the freeze in payment came after PhilHealth learned that the hospitals were “suspiciously admitting” patients for an overnight stay even if they do not have health problems.

 She said that patients would be discharged the next day with doctors’ medical findings that made it appear like the patient had pneumonia.

At the weekly health forum in Quezon City, Padilla said there was nothing wrong with the patients but they were made to stay for a night at the hospitals.

She refused to identify the hospitals pending completion of the investigation, although she said these facilities appeared to have resorted to fraud because “they need money; it’s a way to earn money.”

The “pneumonia fraud,” she added, will allow hospitals to earn millions and the doctors between P15,000 to P32,000 depending on the severity of the case.

Padilla described one of the two hospitals as “a small hospital” – even smaller than St. Luke’s bed capacity – but charges higher than the prime hospital.

In 2014, PhilHealth paid P7.6 billion for pneumonia; P4.6 billion for hemodialysis; P4.2 billion for cesarean delivery; P2.1 billion for removal of cataracts and P1.5 billion for maternity care package.

So far, Padilla said investigation showed that the hospitals hired “door-to-door recruiters” to entice people to become patients in exchange for some payment.

“Sometimes, all the street vendors are hired. On other occasions, they pay patients. Patients connive with what the hospitals want. Everything is corrupted,” she added.

Padilla also urged politicians not to use PhilHealth for their 2016 political plans, believing that this will only worsen the problems the agency is facing.

Recently, PhilHealth found at least six health care facilities that made PhilHealth members undergo cataract surgery even when these are not necessary. The involved hospitals allegedly claimed bigger benefit payments for cataract removal.

“These abusive centers charged P59,000 to P80,000 per eye instead of the usual P16,000. Top cataract centers in respectable hospitals only have three percent of their total eye-care patients go through multiple procedures. But these abusive centers report 90 percent,” Padilla said.

PhilHealth’s benefit payments totaled P56 billion in 2013 and P78 billion in 2014 – an increase of 28 percent.

For this year, Padilla said that PhilHealth is spending about P1.7 billion a week in benefits.

“That’s how much today we are spending. How much of that is fraud? That’s what we have to find out,” she said.

A source at PhilHealth said administrative and criminal charges have been filed against 10 PhilHealth employees, doctors and ranking officials.