MANILA, Philippines – Two eye centers on Wednesday, July 1, asked the Philippine Health Insurance Corporation (PhilHealth) to lift the suspension on their benefit payments which have been tagged as “highly suspicious.”

“Yung mga naghahakot ng (those who gather) patients, they don’t bring patients to us. They bring patients to the doctors,” Dr Raymond Evangelista, owner of Quezon City Eye Center said at the Senate blue ribbon committee hearing on Wednesday.

Evangelista was referring to “seekers” who bring PhilHealth members – especially senior citizens – to health facilities for cataract surgery even without the patients’ informed consent. Through this “modus,” alleged syndicates were able to claim bigger benefit payments from PhilHealth.

From the case rate for cataract removal amounting to P16,000 ($354.39), PhilHealth revealed that in exchange for bringing patients, seekers can get as much as P2,000 per eye ($44.3) from surgeons, and P6,300 per eye ($139.54) from eye centers.

But Evangelista and Pacific Eye Institute owner Dr David Harold Gosiengfiao told senators they don’t employ seekers.

In the case of Quezon City Eye Center, even doctors are not their employees since physicians only use their facilities to treat patients. 

Despite this, the payment for doctors’ professional fees still go through the center. Evangelista said this explains the sudden spike in their claims.

“Nung 2013, hindi lang po yung cataract surgery ang pinapaabot sa amin. Lahat po ng professional fees ipinadadaan na sa center para iabot namin sa doktor. Kaya nung tiningnan namin ‘yung aming mga figures, e ‘yun palang paglobo ay hindi dahil tumataas ang aming reimbursements,” he explained.

(Fees for cataract surgeries were not the only ones coursed through us in 2013. The center hands over all professional fees to the doctor. This is why when we looked at our figures, we saw that the sudden rise in claims was not because our reimbursements increased.)

Responsibility of facility

Since doctors bring in the patients, Evangelista asked PhilHealth if it could spare the health facilities and instead suspend the benefit payments for doctors involved in the issue. Gosiengfiao, for his part, asked at least for the lifting of the suspension on legitimate claims. 

But PhilHealth president Alex Padilla said institutions are also responsible for their doctors.

“The one who files the claim is the facility, not the doctor. The one who receives the claim is the facility, not the doctor. The facility should be responsible for its doctors. They can’t use as an excuse the argument that doctors perform the procedure. They can’t do that. Otherwise, every other doctor or hospital would be escaping liability,” Padilla said in a mix of English and Filipino. 

But doctors are not yet off the hook either. Padilla told Rappler after the hearing that at least 20 doctors are also under investigation, along with the 10 ambulatory surgical centers claiming for cataract procedures. (READ: Harsher law proposed to prevent PhilHealth claims fraud – Guingona)

Removal of cataracts ranked 4th among the top conditions and procedures PhilHealth paid for in 2014. This is equivalent to P3.7 billion ($81.95 million) out of the P78-billion ($1.73-billion) total benefit payments that year.

Aside from Quezon City Eye Center and Pacific Eye Institute, Padilla said they will soon suspend the processing of claims of two other centers. – Rappler.com

US$1 = P45.15