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PhilHealth regional offices investigating hospitals for fraudulent claims: 80 in Eastern Visayas, 4 in Davao

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THE PHILIPPINE Health Insurance Corp. (PhilHealth) is cracking down on hospitals for fraudulent claims involving such schemes as “upcasing” and “patient seeking.” In the Eastern Visayas, Acting Regional Vice-President Michael Jibson C. Hernandez announced on Monday that they have deployed “11 special investigators” to look into 80 hospitals “for fraud/ghost claims,” according to the Tacloban City local government. In Davao, the agency is investigating four hospitals for making about 2,000 fraudulent claims. PhilHealth Davao Regional Vice President Hector Z. Malate said the hospitals, which he did not name, are tertiary level facilities that offer specialized medical care. Mr. Malate, in a forum last Friday, said the claims involve “upcasing,” wherein a simple illness is reported as more complicated to jack up the amount. There are also cases of “patient seeking,” he added, wherein hospitals seek PhilHealth members who can pose as patients for the filing of claims. He cited that last year, the state-run health care provider did not accredit a hospital in Davao del Sur found to be engaged in such practice. Filbert Bryan L. Sollesta, Philhealth Field Operations division chief, also warned members that engaging in these malpractices are punishable under the Universal Health Care (UHC) Act. “Under Section 38.10, the penalty that members face is specified,” said Mr. Sollesta. That provision states that a member who is involved in the filing of fraudulent claim faces “a fine of P50,000 for each count or suspension from availment of benefit of the program for three months but not more than six months or both, at the discretion of Philhealth.” With the UHC law, all Filipino citizens become automatic members of PhilHealth, with varying categories for direct, and indirect contributors, and those subsidized by government. — Carmelito Q. Francisco

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