Forging partnerships to intensify campaign vs health care fraud

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.