LA TRINIDAD, Benguet – Philippine Health Insurance Corporation – Cordillera Administrative Region (PhilHealth-CAR) reported a significant 76% drop in legal cases filed against suspicious healthcare facilities over the region during its first Kapihan sa Bagong Pilipinas on February 11.
Atty. Eric Mandiit, PhilHealth-CAR’s Legal Office Head, stated that of 285 claims endorsed for investigation in both private and government health facilities, only 15 cases were filed as legal cases in 2024. This marks an improvement compared to the 63 cases filed from 208 claims in 2023.
Twelve of the 15 cases involve upcasing, a form of health insurance fraud. This is often a result of a healthcare provider’s intentional mismatching in the offering of government compensations or benefit packages in relation to the patient’s actual medical condition. In the judicial sector, it is recognized as misinterpretation by furnishing false or incorrect information.
“For instance 30,000 [pesos] na yung Moderate Risk [ng pneumonia] … So na-hospitalize siya tapos low risk pala siya, hindi siya compensable. Walang babayaran ang PhilHealth. Pero ang ginagawa is that pwedeng tinaasan niya (healthcare provider), ginawa niyang pasok sa moderate risk para ma-claim sa PhilHealth,” (For instance, moderate risk [pneumonia] costs 30,000 [pesos]. If a person is hospitalized with low-risk pneumonia, it’s not compensable. PhilHealth will not pay anything. But what happens is that the [healthcare provider] makes it sound worse, making it into moderate risk so a payment claim can be made from PhilHealth.) Attorney Mandiit explained.
It was further revealed in the forum that when a patient receives financial assistance from PhilHealth, the healthcare provider also receives a professional fee for the services provided.
The remaining three legal cases fall under violation of the “No Billing Policy” which applies to indigent individuals. This policy stipulates that all government hospitals should not collect any other payment beyond the package rate for services rendered.
The penalties for such violations include suspension of accreditation with the length of suspension to be decided by the adjudication office, and a monetary fine ranging from P10,000 to P100,000.
As of now, the complaint affidavits from 2024 have been submitted to PhilHealth-CAR’s Prosecution Department to further verify fraudulent claims. Some cases are already in the adjudication office and are progressing through court hearings.
Atty. Mandiit attributes this significant decrease in cases to the constant effort to keep in touch with the different healthcare facilities throughout the Cordillera region. Patient visits were done to ensure that patients benefit packages accordingly. An appointed medical doctor has also been appointed to PhilHealth-CAR’s Legal Office to evaluate medical claims and help identify fraudulent claims. These efforts helped streamline the Legal Office’s work in legal proceedings. By Aiyra Marzan
