8 PhilHealth officials, 4 hospital workers face complaint over ‘fraudulent’ COVID-19 claim

NBI-7 director and lawyer Renan Oliva shows some of their case files on allegations of irregularities involving PhilHealth and several hospitals in Central Visayas

CEBU CITY, Philippines – A total of 12 individuals, including public officials and medical practitioners, are now facing complaints before the Office of the Ombudsman in the Visayas over allegations of fraud involving coronavirus disease 2019 (COVID-19) claims.

Operatives from the National Bureau of Investigation in Central Visayas (NBI-7) filed multiple criminal and administrative complaints against eight officials from the Philippine Health Insurance Corp. (PhilHealth) and four officers from a private hospital in Cebu City when they discovered irregularities in a patient’s health claims.

The cases included alleged violation of the Anti-Graft and Corrupt Practices Act, Code of Conduct and Ethical Standards of Public Officials and Employees, and Malversation of Public Funds.

They were filed before the Ombudsman past 9 a.m. on Thursday, October 29, 2020.

In a follow-up press conference, NBI-7 director and lawyer Renan Augustus Oliva said their decision was in line with the mandates from President Rodrigo Duterte, tasking the Department of Justice to conduct an investigation on allegations of anomalies plaguing PhilHealth.

RELATED STORY: Duterte will ask Congress to abolish PhilHealth

NBI-7 named PhilHealth-7 officials Arlan Granali (acting regional vice president), Dr. Francis Javier (HCDMD division chief), Dr. Joan Tiu-Ayuson (Benefits Administration Section chief), Josette Bacalso (Fiscal Controller), Dr. Reginal Mangubat (Benefits Administration officer), Anecito Ramas Jr. (Social Insurance Officer), Anthonneette Lerios Maamo (Benefits Administration clerk), and Kenneth Aguilar Donalvo (Social Insurance Assistant) as respondents.

They also lodged formal complaints against several workers from  Perpetual Succour Hospital Inc., a hospital based in Cebu City, namely Sister Brenda Mondares (financial management manager), Gladys Sarmiento (assistant department manager), and billing officers Jaye Anne Carcueva Arañas and Gina Misagal.

CDN Digital has already reached out both to PhilHealth-7 and Perpetual Succour Hospital Inc. for their statements but as of this posting, only PhilHealth-7 responded, saying they will be issuing a statement within the day.

Patient X

Oliva said this stemmed from their findings that the officials and hospital officers allegedly connived to siphon over P300,000 in COVID-19 claims from a patient, referred to as Patient X, who died due to other causes last May.

NBI-7 requested not to divulge the full identity of the patient, citing confidentiality agreements.

“This is an example of an ‘upcase’ wherein the patient’s medical case rate package (for PhilHealth claims) was updated, upgraded,” said Oliva in a mix of Cebuano and English.

PhilHealth, in its official website, defined upcasing as a fraudulent practice among healthcare providers in which benefits and claims were padded to collect higher reimbursements.

In the case of Patient X, Oliva said his living relatives were surprised when they received information from the state-ran firm that severe COVID-19 claims amounting to P333,519 were credited to Perpetual Succour Hospital.

This, despite the fact that Patient X’s death was due to non-COVID-19 pneumonia, and that he already tested negative for SARS-CoV-2 in at least three tests, including a real-time polymerase chain reaction (RT-PCR), prior to his death.

“Claims for non-COVID pneumonia only amounted to P32,000. This is called an upcase because his claims were updated to severe COVID-19 in which the hospital can get P333,519 from PhilHealth,” explained Oliva.

He added that when investigators asked the hospital and PhilHealth about their discovery of an upcase, the latter attempted to reason it out multiple times.

One of them was PhilHealth’s Circular No. 9, Series of 2020, and that they reportedly forgot to put the patient’s RT-PCR test showing he was positive for COVID-19.

However, Oliva said, their responses were not supported.

More cases

But the case involving Patient X will not be the last as NBI-7 disclosed that their bureau is investigating over 100 cases of possible fraudulent COVID-19 claims in Central Visayas.

““We’re investigating tons of claims for COVID-19. And there is a likelihood that there could be cases claimed as COVID-19 but the truth is, they are not,” said Oliva.

Cebu City was once tagged as the epicenter of the COVID-19 outbreak in Central Visayas, and last June, it was the only area in the country that was reverted back to enhanced community quarantine (ECQ) due to rapid transmission of the virus.

/bmjo