NBI ready to probe ‘upcasing’ of PhilHealth claims — DOJ

MANILA, Philippines — The National Bureau of Investigation (NBI) is ready to probe allegations of “upcasing” or the connivance between patients and health care providers to bill bigger COVID-19 claims from the Philippine Health Insurance Corp. (PhilHealth).

This was the assurance given by Department of Justice (DOJ) Secretary Menardo Guevarra yesterday to PhilHealth president and chief executive officer Dante Gierran amid reports of anomalous claims.

Guevarra expressed confidence that Gierran, being a lawyer and former director of the NBI, would be able to identify those reportedly engaged in the scheme to defraud the state health insurer.

“The DOJ-led Task Force PhilHealth conducted a thorough investigation of ‘upcasing’ schemes last year and cases were thereafter filed. PhilHealth is currently looking into new incidents of upcasing in relation to COVID-19 claims,” Guevarra said.

“With a former NBI chief as president/CEO, PhilHealth can very well handle this new investigation. But the DOJ/NBI will be ready to provide assistance if requested,” he added.

Earlier, PhilHealth said that it would look into the proliferation of video posts reportedly showing health care providers apparently colluding with patients with minor respiratory ailments such as asthma and presenting them as a COVID-19 case in order to claim bigger benefits from the state insurer.

It also asked those who posted the videos to provide proof and to fully cooperate with the investigation.

Those found guilty of upcasing may be fined P200,000 for each count or have its health care provider contract suspended, or both.

The act also constitutes a criminal violation punishable by imprisonment of six months and one day up to six years, upon the discretion of the court in accordance to Section 38 of the Universal Health Care Law.

On the other hand, if the accusations against health care facilities are found false and not backed up by evidence, the case may fall under cyber libel and violation of Article 154 of the Penal Code criminalizing publication of false information that may endanger the public order or cause damage to the interest or credit of the state.

PhilHealth to settle valid claims

More than half of the “valid” reimbursement claims of hospitals with PhilHealth will be settled, the Department of Health (DOH) said yesterday.

DOH Undersecretary and treatment czar Leopoldo Vega said 60 percent of reimbursement claims of hospitals in the National Capital Region (NCR) and the adjoining provinces of Bulacan, Laguna, Rizal and Cavite will be paid.

At a public briefing, Vega noted they have been working with various public and private hospitals and they have agreed to “help us and support the government in terms of the allocation of more beds” so they can accommodate more COVID-19 patients.

“For treatment capacity, for the last two weeks, we have engaged the different government and even the private hospitals that they have to increase their bed capacity because this is in relation on what they receive from PhilHealth,” he added. – Sheila Crisostomo