The Philippine Health Insurance Corporation or PhilHealth in short, is set to
conduct on April 4 at the Oriental Hotel Leyte, a Regional Multi-Sectoral
Anti-Fraud Awareness Forum aimed at promoting awareness among health care
providers and other stakeholders the significance of its anti-fraud program.
PhilHealth Regional Vice
President Walter Bacareza informed that the forum will foster public-private
partnership with various stakeholders in the fight against health care fraud.
“We have invited our partner
health care providers, government agencies, local government units,
non-government organizations, civil society organizations, medical societies
and accredited collection agencies to join us in this activity,” VP Bacareza
said.
No less than Health Secretary
Enrique Ona, the OIC President and CEO of PhilHealth and the members of the
board of directors are expected to attend the Forum to share their perspective
on the anti-fraud campaign, the Regional Vice President of PhilHealth added.
It
may be recalled that allegations of fraud crop up every now and then in the
country’s health insurance system. Together with abuse and adverse selection,
they comprise the triple threat that could potentially compromise the viability
and sustainability of social health insurance schemes.
Fraud
and abuse in health care come in various forms. In the old Medicare program, documents and
signatures of members were purchased; and/or claims were manufactured and
submitted for non-existent admissions. These so-called “ghost” admissions
unfortunately almost always involved hospitals. Related to these were “family
or barangay confinements” wherein several family members or members of the same
barangay were admitted at the same time despite the absence of epidemics.
It was learned that another
phenomenon is the recycling of patients wherein a “cycle of admission” is
observed. Here, members were usually admitted for acute illnesses, re-admitted
after a few weeks or months in the same or nearby hospital, and then admitted
again in either of the hospitals.
There were the “weekend confinements” where at least 50% of claims submitted by
hospitals are incidentally admitted on Fridays or Saturdays then discharged
Sunday or early Monday. Interestingly, this is contradictory to the usual
Filipino confinement preference – being discharged on a Friday and deferring
elective admissions until after the weekend.
In
addition, there are the routine fraudulent and abusive practices which include
declaring non-dependents as dependents; borrowing of identity; confirming
eligibility despite being ineligible, up-coding of disease and procedure codes;
and falsifying diagnosis and confinement dates.
There are also schemes referred to as the worst manifestation of adverse
selection anywhere in the world. Adverse selection is a technical term that
describes behavior in a “voluntary” health insurance system scheme wherein
those who are most likely to require hospital care are those who join the
scheme. This behavior, which compromises the insurance fund, has prompted
country after country all over the world to make membership mandatory.
The
National Health Insurance Act of 1995 that created PhilHealth has long stated
that membership is mandatory. However, while this provision has been
implemented for most part of the formal sector, it is not yet
fully mandatory for the whole informal sector.
This
has resulted to the unethical practice of “patient recruitment” wherein health
care providers themselves pay the premium of patients whom they will then treat
once the patient has become eligible for benefits. In PhilHealth’s case,
eligibility usually takes effect 6 months after premiums were paid for the
first three months. For elective surgeries of self-paying members, eligibility
vests after 9 months.
Faced
with the challenge to minimize and eventually prevent these practices, PhilHealth
set up a Fraud Prevention and Detection Unit, now called the Fact Finding
Investigation and Enforcement Department.
Together
with the legal units in the regional offices, it is working hard to build cases
against fraudulent and abusive health care providers. Fifty
anti-fraud personnel have been deployed for intensive daily monitoring of ‘tagged’
health care providers. Moreover, a total
of 530 PhilHealth CARES nurses are present on hospital grounds to help ensure
that only accurate information on diagnosis and treatment are submitted by
providers.
The
Prosecution Department has proactively filed cases against several erring
hospitals and doctors and PhilHealth is committed that these cases will be
quickly acted upon.
PhilHealth
is also partnering with health information technology providers to make
electronic claims submission a reality soon.