MANILA, Philippines – Lacking enough personnel, the Health Facilities and Services Regulatory Bureau of the Department of Health (DOH) said it is able to check only licensed eye clinics in Metro Manila and nearby areas to prevent fraudulent insurance claims.

“Their proximity to Manila makes it easier for us to monitor them before we spread out to the provinces because of our limited resources,” Health Assistant Secretary Nicolas Lutero, the bureau’s director, said on Thursday, July 23.

Lutero was a resource person during the 3rd Senate blue ribbon committee hearing on questionable Philippine Health Insurance Corporation (PhilHealth) claims made by eye clinics. 

PhilHealth is investigating top 10 ambulatory surgical centers – mostly located in Metro Manila – claiming for cataract procedures after they discovered a “very conspicuous rise” in claims which also coincided with complaints from patients. (READ: How eye clinics ‘syndicates’ defraud PhilHealth)

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

PhilHealth learned that doctors in some clinics not only use “seekers” to entice patients to consult with them. Some doctors even perform “unnecessary” laser procedures to claim more benefits from PhilHealth.

‘Act as one’

Even before this issue came up, Lutero said they had monitored 5 out of 38 clinics “specifically dealing with eye problems.”

But he admitted their monitoring is not done on a regular basis. In fact, this is a weakness of their system, he said during the July 8 Senate hearing on the issue. 

“After the license [of health facility] is issued, monitoring is a problem…. But if we receive reports like this from PhilHealth, then we take action,” he said then.

Health Secretary Janette Garin, who was present during Thursday’s hearing, said that while any facility accredited by DOH is “deemed accredited” by PhilHealth, the latter has the power to suspend the facility’s PhilHealth accreditation.

But Senator Teofisto Guingona III, chair of the Senate blue ribbon committee, said this is exactly what the health department should look into, especially in connection with institutions found guilty of violations such as fraud. 

“I think you should address that, because why will you have an institution whose right to claim payments has been suspended continue operating as a hospital?” he said.

He urged both DOH and PhilHealth to “act as one.” 

“It can’t be like this, that there are red flags, but they were not monitored, or the basis of monitoring them is the proximity to Metro Manila…. How many people have to go blind before we start an honest-to-goodness nationwide monitoring?“

Taking note of lapses in monitoring, Garin has already tasked Lutero to focus on handling health facilities in the country.

Before, he had to juggle this task with other obligations as chief legal officer of DOH and director-general of the Food and Drug Administration (FDA).

“After conferring with him and taking note that the Bureau of Health Facilities actually holds a very vital position and the task is so extensive, I have decided to put a core team to manage FDA and myself overseeing it, and the legal office is already being handled by an OIC,” Garin explained. – Rappler.com