Zubiri Exposes PhilHealth Fraud Schemes: Rebates, Ghost Patients, Legal and Admin Cases Schemes

Upon Tuesday's resumption of the Senate Committee on the Whole's hearing on the alleged corruption in the Philippine Health Insurance Corporation (PhilHealth), Senate Majority Leader Juan Miguel Zubiri gave a rundown of the corporation's history of corrupt practices, from its unreleased Interim Reimbursement Mechanism (IRM) funds to its non-existent and ghost patients, before exposing a number of questionable legal and administrative cases within PhilHealth.

Unreleased IRM

In addition to Ospital ng Maynila not receiving their IRM funds worth P 19.3M, Zubiri revealed that PhilHealth has also so far failed to act on the IRM fund applications of at least two other government healthcare institutions (HCIs). Western Visayas Medical Center (WVMC) in Iloilo City has reported P 121.4M in unreleased IRM funds. In Bacolod City, the Corazon Locsin Montelibano Memorial Regional Hospital (CLMMRH) is still waiting for the release of P 41.7M.

Both WVMC and CLMMRH are handling COVID-19 cases.

Non-Existent and Ghost Patients

Zubiri also put a spotlight on the troubling phenomenon of nonexistent and "ghost" patients.

The Senator brought up Golingay General Hospital in Malalag, Davao del Sur, as a prime example of the non-existent patient scheme. The infirmary, with its mere 18-bed capacity, received P 18M in claims in 2014, and almost P 10M in just the first semester of 2015.

Ghost patients, meanwhile, are common in dialysis cases, Zubiri claimed, saying that there are hospitals that still claim unused dialysis sessions of patients who pass away before completing their 90-day sessions.

He also alleged cases of upcasing in HCIs—the fraudulent practice of elevating minor illnesses for higher claims. Some HCIs, Zubiri said, upcase hypertension to mild stroke and charge as much as P 25,000 per claim.

Zubiri also revisited the case of Pamela del Rosario—a supposed cancer patient from a hospital in Region 1. Her case report indicated that she, as well as both her parents, had cancer. This family was able to claim P 1.7M. However, the National Bureau of Investigation later found that Ms. Del Rosario and her family were entirely nonexistent.

This has been well documented within PhilHealth as a clear case fraud. However, stringent legal action has yet to be done.

Legal and Administrative Cases

According to Zubiri, the Legal Sector and the PhilHealth administration are to blame for the continued proliferation of these schemes.

"Problem number one, orders from the Legal Sector to ignore court rulings on fraud. Supreme Court and Court of Appeals Final Decisions on suspension of hospitals have remained unimplemented or ignored by PhilHealth," he said. He cited the CA decision on Perpetual Succor Hospital in Cebu, and the SC decision sustaining the suspension of General Santos Doctors Hospital for being found guilty of claiming payments for ghost patients. The former remains unenforced, while the latter has been put on hold.

In the Pamela del Rosario situation, Zubiri revealed that cases against PhilHealth employees involved in the fake cancer claims were severely downgraded and then eventually dismissed.

"Atty. Emily Roque filed only charges for simple misconduct against ten employees who had been positively identified by PhilHealth Anti Fraud Personnel," he explained. "Last year, the cases against these employees were dismissed."

"The Fact-Finding Investigation and Enforcement Department personnel submitted a 200-page comprehensive report which was reduced to a twenty-page report by Internal Audit Department," he said. The original report clearly identified the role of each employee in the scam. This was lost in the Internal Audit report. Zubiri moved that the Senate subpoena the 200-page report.

Furthermore, Zubiri pointed out that while majority of the claims in the Regional Office were being processed at sixty days, the Del Rosario claims were processed at an average of only ten days.

Zubiri dug up further shortcomings of the Legal Sector, saying that SVP for Legal Rodolfo del Rosario Jr. has thus far failed to act on 220 cases against fraudulent HCIs.

"Then-Region I RVP Rodolfo del Rosario refused to act on a directive from former OIC PCEO Dela Serna to file 200 counts of charges against Corpuz Hospital for documented fraud," Zubiri explained. These unfiled cases were remanded to the Legal Sector in 2019.

Del Rosario is now SVP for Legal. The cases remain unfiled.

"Kaya walang natatakot na mga erring HCIs, walang natatakot na hospital, dahil nga hindi naman sila kinakasuhan at hindi po sila pinaparusahan," Zubiri said. "Ang malaking parusa kasi ay yung suspension ng accreditation—na hindi po ginagawa ng previous PhilHealth administrations."

"Paano natin maaayos ang katiwalian sa PhilHealth kung wala namang kaso na fina-file at wala pong mga taong ikinukulong? Kung ganito ang pangyayari diyan sa loob ng PhilHealth?"

Having laid out the schemes within PhilHealth, Zubiri has revealed the corporation's inter-departmental, cross-regional corruption to be a complicated web of fraudulence that is protected by PhilHealth's own legal and administrative mechanisms.