‘Digitize PhilHealth data to curb fraud’

MANILA, Philippines — There is an urgent need to digitize the Philippine Health Insurance Corp. (PhilHealth) database and upgrade its information technology (IT) system to reduce fraud and improve efficiency, Sen. Sonny Angara said yesterday.

Angara, who chairs the Senate committee on finance, called for a strengthening of the anti-fraud mechanisms in PhilHealth to include a special audit on its funds, following the most recent controversy faced by the state health insurer involving its allegedly overpriced IT system and the controversial P27-billion Interim Reimbursement Mechanism (IRM).

Another senator, Christopher Go, said it should be the mission of the next PhilHealth chief to restore the firm’s integrity in order to give Filipinos the assurance that their money is being spent to improve access to quality health services rather than being lost to corruption.

He said President Duterte is set to announce the next PhilHealth chief today, following Ricardo Morales’ resignation as PhilHealth president due to health reasons last week. Morales was accused of heading a “mafia” within the agency.

Go challenged the next PhilHealth chief to balance improving the state health insurance agency’s services while ending corruption.

Angara said the state health insurance firm should digitize its records and to utilize systems to validate membership claims just like what is being used by pension funds Social Security System and Government Service Insurance System.

“They (PhilHealth) should likewise look into strengthening their manpower complement by hiring more medical reviewers, anti-fraud officers, data scientists, data analytics personnel, and even experts in artificial intelligence and big data,” Angara said.

The need to immediately digitize its records was highlighted during the Senate hearings where Morales disclosed that about 5,000 members are 130 years old and that nobody knows if they are dead or alive.

Earlier this week, a television report noted how a senior citizen was told that he was already dead for almost four years based on his PhilHealth member data record.

The senator has been pushing for the digitization of both the government and private sector as part of the national digital transformation program to improve efficiency in the delivery of services and prepare the country for the requirements of a rapidly changing world.

This is contained in Senate Bill 1470 of the proposed National Digital Transformation Act, which Angara filed last May 4.

He also reiterated his call for PhilHealth to immediately release detailed guidelines on the deferred liquidation of the coronavirus disease’s IRM funds.

“PhilHealth, being a recipient of government funds, should ensure that these are paid, released and accounted for according to existing rules and regulations,” Angara said.

He also proposed an amendment of the Universal Health Care Act to include the mandatory audit of PhilHealth’s finances and to provide copies of the annual report to the Congressional Oversight Committee, the Senate committee on finance and the House committee on appropriations.

A comprehensive review on PhilHealth’s implementation of All Case Rates claims payment scheme, including the re-calculation of the top 32 case rates for at least 90 percent of cases or claims filed was also recommended by Angara as part of his inputs to the drafting of the committee report on the hearings.

He previously noted how there were questionable case rates wherein some minor procedures or ailments would be paid more by PhilHealth than critical conditions.

This has also led to the practice of upcasing or when a health facility would upgrade certain ailments such as simple cough and colds to more serious conditions like pneumonia in order to collect bigger payouts.

During the Senate hearings, he cited the claims for pneumonia recorded a sudden jump from less than P3 billion a year between 2009 and 2011 to P9.7 billion in 2015. From 2017 to 2019, claims for pneumonia have averaged at P10.5 billion a year.