NBI-7 files charges against PhilHealth-7, hospital officials for upcasing

By: Mae Fhel Gom-os - CDN Digital | July 02,2021 - 07:30 AM
PhilHealth

Atty. Renan Oliva, National Bureau of Investigation (NBI-7) Director, speaks during a press conference on Thursday, July 1, 2021. CDN Digital photo | Mae Fhel Gom-os

(Updated, 12 noon, July 2) CEBU CITY, Philippines – Officials of the Philippine Health Insurance Corporation in Central Visayas (PhilHealth-7) and a private hospital are facing charges before the Office of the Ombudsman Visayas for upcasing the cause of death of a patient into COVID-19 last May 2020, even if two test results showed negative results.

The National Bureau of Investigation in Central Visayas (NBI-7) filed Anti-graft and Corrupt Practices Act and Malversation of Public Funds or Property charges against eight PhilHealth-7 officials and six hospital officials.

PhilHealth-7 officials include acting regional vice president Arlan Granali; Division Chief Francis Javier, M.D. ; Medical Specialist Joan Tiu-ayuson, M.D.; Fiscal Controller Josette Bacalso; Anthonneette Camahalan Ramas; Nina Christine Lunday; and Kenneth Donalvo.

Those charged from the Adventist Hospital in Cebu City are Dr. Michelle Francisco-Napigkit, who served as the attending physician of the patient; Cefriano Julian Jr; Ma. Kenneth La Sage; Dicchel Grace Napigkit; Red Ford Gargarila; and Romeo Rando Jr.

Allegedly, officials of the Adventist Hospital in Cebu City claimed that a patient died due to severe COVID pneumonia despite two tests (anti-body and RT-PCR ) showing negative results.

NBI-7 Director Renan Oliva said PhilHealth officials approved the claim and released the amount of P333, 519 amid the attached two negative results of the patient.

“Bisag naka-attach ang results didto, gi-approve sa PhilHealth as COVID. That is why gi-filean nato sila og kaso. It was clear from the attached documents transmitted by the hospital to PhilHealth nga negative ang result. So this is another case of upcasing. Ang ilang gibasehan katong medical certificate nga gi-issue sa ilahang doctor nga COVID-probable,” said Oliva.

Upcasing is the practice of some health providers to pad claims to collect higher reimbursements.

Oliva said they looked through the guidelines for the implementation of the benefits which had only two options, either probable or confirmed.

A probable case is a suspect case that fulfills any of the following: suspect case whom laboratory testing for COVID-19 is inconclusive; suspect who underwent testing for COVID-19 but not conducted in a national or subnational reference laboratory or officially accredited laboratory for COVID-19 confirmatory testing; and suspect case for which testing could not be performed by any reason.

Oliva said the patient, a retired bank employee, was confined last May 27, 2020 at the hospital due to cough and shortness of breath, with an initial diagnosis of “Ambulatory” and “Acute Respiratory Faialure Secondary to Pumonary Tubercolosi.”

The same day the said patient was subjected to Anti-body test and RT-PCR test.  Unfortunately, the patient died the next day, May 28.

The anti-body test result, which was released prior to his death, showed negative of COVID-19.

Despite the test result, Napigkit, who served as the attending physician, issued the patient’s death certificate with an underlying cause of COVID Pneumonia Probable, Severe, which also reflected on the patient’s medical certificate and clinical abstract.

The RT-PCR specimen, on the other hand, which was forwarded to Vicente Sotto Memorial Medical Center (VSMMC), was released on June 3, 2020, which further revealed that the patient was negative of COVID-19.

He emphasized that at the height of the pandemic, only accredited hospitals such as VSMMC were allowed to conduct RT-PCR testing.

“Sotto is accredited national laboratory. Unya suspect case for which testing could not be performed for any reason. Wala mo fall sa COVID. Dili gyud siya COVID. Negative ang RT-PCR and Anti body, and yet gi-issuehan, that is why gi-chargean nato ang doctor nga COVID ang iyang gibutang sa death certificate,” said Oliva.

On June 15, 2020, the hospital officials prepared the PhilHealth claim documents and allegedly used the false death certificate as basis when they submitted it to the government-owned insurance company, pursuing to claim the benefit package amounting to P333,519.

Based on the result of the investigation, PhilHealth approved and released the claim on July 20, 2020 with all the attachments, including the negative RT-PCR test and Anti-body test.

“Mahibong ka unsa may basis nato kon moingon og probable COVID, specific man ang unsay definition sa probable case,” said Oliva.

“Basically, it’s a negative RT-PCR test nga gi-claim nga positive to get a higher value when in truth and in fact, ni-fall ni sa ordinary pneumonia. Not COVID-pneumonia. So that is corruption,” he said, as he noted the huge difference stressing that an ordinary pneumonia case could only be reimbursed with the amount of p15,000 to p32,000.

He said the PhilHealth and hospital officials were sent subpoenas during the investigation but they opted to remain silent and that others even brought their lawyers with them.

Oliva revealed that this is the third case of upcasing that they have found out so far, saying that all their cases are strong.

“Unya ang atong gi-charge nga mga tawo based sa signatories, namirma sa approval sa claim ug sa nag-claim. That is why limited, as far as hospital is concerned ang atong gi-charge ang katong ga billing kay mao nay ni-reflect sa mga signatories nga gi-claim. They’re the ones authorised to evaluate the claims kay mo attached man kag mga documents in support of your claim. Kinsa may charge ana. We cannot file cases against those nga wala mo review diri sa documents sa claim. And as part sa Philhealth, ang katong ni-approved sa release sa kwarta,” he said.

Oliva noted that some of the officials who are currently facing charges in this case are the same officials in two previous cases which involved two other hospitals.

“If you attempt to do this, documentary man gud, there is a paper trail when i-audit mo or naay motion sa papers, makit-an gyud ang irregularity. You have signatories there, documents supporting the claim, maklaro ni kon irregular ang imong claim. Kato nang claim ani, is you are making it appear na you are claiming for COVID positive when the document say otherwise nga COVID negative. Kay ang RTPCR test, negative man. Unsaon man nimo pag claim nga sa positive. I-evaluate nimo one by one ang documents, makita man nimo. Masakpan ra gyud basta voluminous lang gyud ang documents,” said Oliva.

Additional administrative charges were also filed for the eight PhilHealth offocials for the violation of the Revised Penal Code of 1987 such dishonesty; neglect of duty; misconduct; inefficiency and incompetence and in the performance of official duties; and for conduct prejudicial to the service.

Meanwhile, the attending physician is facing additional criminal charges for issuing false medical certificates.

Oliva said they are waiting for the response of the Ombusdman concerning the charges, stressing that most probably the officials will be asked to respond to it.

PhilHealth-7, meanwhile, released an official statement regarding the matter.

/bmjo

READ MORE: PhilHealth revising coverage policies for COVID-19, other cases

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TAGS: Director Renan Oliva, NBI-7, PhilHealth, Philippine Health Insurance Corporation, upcasing

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