Patay malisya! Philhealth pays Zamboanga hospital P40M despite discovering fraudulent claims
By Nancy Carvajal
The Philippine Health Insurance Corporation (PhilHealth) continued paying a hospital in Zamboanga City for years despite discovering that it was filing fraudulent claims, results of a probe by the National Bureau of Investigation (NBI) showed.
Jenomar Tandong, the NBI officer assigned to the case, told Politiko that Philhealth’s regional office in Region 9 even pushed for a filing of a case against the Eastern Sun Medical Diagnostic Center (ESMDC) but it fizzled out.
In 2014, PhilHealth Region 9 conducted an investigation on ESMDC’s supposed bogus claims and serious violations of PhilHealth rulescarried out by hospital owners and officials. The agency then forwarded the result of the investigation to the Prosecution Department of the PhilHealth National for appropriate action.
However, despite the derogatory findings of PhilHealth Region 9 office, ESMDC continued to operate and received payments from the state insurer.
PhilHealth paid even paid ESMDC the amount of P39,757,547.99 or roughly P40 million for year 2015, after the derogatory of the local office was submitted to the PhilHealth national office.
It’s noteworthy that the amount paid to ESMDC by PhilHealth was the same exact amount it paid the hospital for 2014, up to the last centavo.
ESMDC based in Siocon town in Zamboanga City received a total of P92 million from PhilHealth for five years from 2013 to 2018 by supposedly manipulating medical records of patients treated in medical missions, the NBI said.
Last year NBI filed a case of syndicated estafa against the owners and officials of ESMDC before the City Prosecutor’s Office.
Tongdo said,until today the prosecutor’s office have yet to issue a resolution on the case for probable cause.
Recommended for prosecution were Ceasar C Soriano, Dr Fidel Pondevida Jr., Tasnemah A. Pangandaman, Dr Kristine Prayon, Dr. Rukmini A. Alip and Dr. Cynthia Soriano Superable.
Among the adverse findings of the local PhilHealth was a claim for the confinement of dependent-patient from April 12 to 14, 2014 due to Pneumonia Moderate Risk, where the patient should have been treated as out patient.
For purposes of filing a claim with PhilHealth, the hospital also made to appear in the submitted Claim Forms 1, 2 and 3 that the attending physician was the PhilHealth accredited physician, but who actually attended to the patient was a non-accredited physician.
The record also showed that payments for 2015, covered only the first eight months of the year, and no claims were made from August till December.
In 2016, the hospital filed a full year insurance claim of P9.6 million.
The hospital received around P1.5 million for its operation for the first six months of 2017.
It also noteworthy, that the hospital continued to operate and received reimbursements of millions of pesos from PhilHealth, even it was supposed to have been shut down on the virtue of a local government resolution.
The same record showed that the hospital continued to received payments from PhilHealth until 2018, though for a measly sum of P2,744.
Apart from Siocon, ESMDC was also recruiting residents in nearby municipalities RT Lim, Tungawan, Sibugay, Gutalac, Labason, Liloy, Godo, Salug,Leon Postigo, and Sindangan located in another congressional district, including the town of Sibuco.
ESMDC ferried patients numbering between 30 and 60 people at least three times a week from various towns in Zamboanga to be brought to the hospital in the guise of medical mission and for free medical examination.