MANILA, Philippines – The Philippine Health Insurance Corporation (PhilHealth) has temporarily stopped the benefit payments for two hospitals involved in fraudulent insurance claims, this time for pneumonia cases.

“[We stopped the payment for one hospital] just the other day; the other one, about the same time as the eye centers,” Dr Minguita Padilla, the head executive staff of the health secretary, said during a Philippine College of Physicians forum on Tuesday, August 4.

Without naming the facilities, Padilla described both as “private provincial hospitals,” one of which is located “in the north” and the other in Mindanao. 

“Sometimes, glaring [ang fraud]. May 44-bed hospital pero ‘yung kaniyang pneumonia cases mas mataas pa kaysa sa St Luke’s [in Global City]. ‘Di ba masyadong obvious? There’s something wrong,” Padilla, who also chairs the Eye Bank Foundation of the Philippines, added.

(Sometimes, the fraud is glaring. It’s a 44-bed hospital, but the pneumonia cases are higher compared to St Luke’s in Global City. Isn’t it too obvious? There’s something wrong.)

During the first Senate hearing on questionable PhilHealth claims on July 1, PhilHealth President Alex Padilla revealed how abuse happens when hospitals claim benefit payments for pneumonia cases.

“Mukhang ang nangyayari doon ay tinatawag naming upscaling: ubo lamang o sakit ng lalamunan ay inu-upscale nila into pneumonia para lang makuha ‘yung aming reimbursement…when in fact dapat hindi namin binabayaran kung ito ay simpleng ubo lamang,” he said.

(It looks like what happens there is what we call upscaling: a simple cough or sore throat is upscaled into pneumonia so they can claim our reimbursement…when in fact we shouldn’t be paying cases that involve simple cough.)

According to the World Health Organization, pneumonia is a form of acute respiratory infection that affects the lungs. PhilHealth’s case rates for pneumonia amounts to P15,000 ($328.75)* for moderate-risk, and P32,000 ($701.33) for high-risk.

Pneumonia is the top health condition PhilHealth paid for in 2014. This is equivalent to P7.6 billion ($166.6 million) out of the P78-billion ($1.71 billion) total benefit payments that year.

‘Difficult to monitor abuse’

Unlike the fraudulent claims for cataract surgeries which amount to about P2 billion ($43.84 million), PhilHealth has no exact figures yet on how much is involved for pneumonia cases. But millions are involved, Minguita Padilla said.

PhilHealth will soon release its patient care standards for pneumonia cases. This will prevent “abusive claims” by some hospitals that admit patients and diagnose them with severe pneumonia.

These patients are discharged the day after instead of being admitted to the intensive care unit, which is usually the case for patients with severe pnuemonia. 

Alex Padilla earlier admitted it’s more difficult to monitor abuses involving pneumonia cases. (READ: Harsher law needed to prevent PhilHealth claims fraud – Guingona)

“Mas mahirap, may kaibahan nang kaunti ‘yung pneumonia dahil diyan, kailangan naming pumunta sa actual clinical findings sa baba, makausap ‘yung pasyente mismo at iba pang testigo,” he said.

(It’s more difficult, there’s a difference for pneumonia because with that, we have to go to the actual clinical findings on the ground, talk to actual patients and other witnesses.)

PhilHealth earlier suspended the processing of claims of Pacific Eye Insititute-Makati and Quezon City (QC) Eye Center – two of the 10 ambulatory surgical centers under investigation for questionable PhilHealth claims for cataract procedures.

QC Eye Center recently filed a libel complaint against officials of PhilHealth, and a P34-million ($745,319.57) civil case against PhilHealth for damages from abuse of rights and breach of contract. (READ: Eye clinics: ‘Seekers’ bring patients to doctors, not to us) – Rappler.com

Pneumonia patient’s x-ray image via Shutterstock

*US$1 = P45.63