PhilHealth set to file cases over fraudulent claims
AFTER more than a year of investigation, a formal complaint will be filed soon against a former PhilHealth employee, hospital staff and an outsider suspected to be part of the conspiracy to defraud PhilHealth and deprive members of benefits due them.
The case will be filed by the City Prosecutor Office against the three suspected to be behind the discovered fraudulent claims in PhilHealth’s Region 1 office.
Atty. McDonald Malicdem, PhilHealth’s Region 1 legal officer, said from the nine employees investigated, the case against only one employee was initially endorsed to be filed by the prosecutor’s office.
“A hospital staff and a private citizen were also identified to have connived with the employee in the fraudulent claims”, said Malicdem.
Malicdem said the suspect is no longer employed in PhilHealth but refused to identify the persons until the case has been filed.
The reported irregularities, particularly the double-claim benefit for a member, were discovered by the central office in October 2014 when a member filed for re-adjustment only to find out that it was processed as a new claim instead.
PhilHealth Region 1 office was immediately asked to explain and an Anti-Fraud Team was created to investigate.
“Some reimbursements of claims were reportedly filed by an employee, not by members, but the processing was fast-tracked and the same employee who is related to the member, withdrew the amount of reimbursed claims”, explained by then PhilHealth Region 1 vice president Dr. Leo Douglas Cardona Jr.
Further probe revealed that the alleged irregularities have been going on since 2009.
However, the alleged fraudulent claims peaked after the implementation of ‘all case rates’ last 2013.
Meanwhile, Malicdem said the system of the agency was improved especially in the claiming of member benefits to avoid the same problem.
“The system was changed drastically and we have addressed the lapses so that there will be no room for irregularities such as this”, said Malicdem. (Hilda Austria)
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