PhilHealth scam: ‘Unnecessary’ laser procedures done on patients

Jee Y. Geronimo
PhilHealth scam: ‘Unnecessary’ laser procedures done on patients
How do eye clinics get more claims from PhilHealth? Health officials say doctors do unnecessary procedures after a patient's cataract surgery, causing more harm

MANILA, Philippines – Doctors in some eye clinics in Metro Manila performed “unnecessary” laser procedures just so they can claim more benefits from the Philippine Health Insurance Corporation (PhilHealth), health officials said on Wednesday, July 8.

The Senate blue ribbon committee invited on Wednesday two PhilHealth patients, who testified on how their eyesight worsened after their eye doctors performed questionable procedures on them.

One of them is Romeo Fernando, who, in 2012, went through two separate cataract surgeries for both of his eyes at Borough Medical Care Institute.

The first surgery on his left eye went well, but Fernando said the surgery on his right eye – done by a certain Dr Cabrera – was very painful.

He eventually went blind in his right eye. Based on his testimony, he later went to a different eye clinic – the Pacific Eye Institute – in hopes of improving the condition of his eyes. 

But Dr Robert So, head of the internal audit group of PhilHealth, said “unnecessary” laser procedures were done on both of Fernando’s eyes two years after his cataract surgeries.

On March 6, 2014, the same Dr Cabrera performed a YAG laser capsulotomy on Fernando’s blind eye.

According to the Philippine Academy of Ophthalmology, this “uncommon” procedure is usually done one year up to 5 years after a cataract surgery, once complication occurs. The laser removes the opacification that has developed on the posterior capsule of the lens.

Una po, ‘pag bulag na ‘yung mata, nag-YAG laser pa po, mukhang ‘di na kailangang gawin ‘yun. At nag-claim pa sa amin itong doktor through the eye center,” So said.

(First of all, when the eye is already blind, the YAG laser is no longer needed. But the doctor still claimed [his benefits] with PhilHealth through the eye center.)

Red flags

Meanwhile, 4 laser procedures were done on Fernando’s left eye, also in 2014. PhilHealth’s claims data showed that two of the claims involved laser treatment for diabetic retinopathy, while the other two involved YAG laser capsulotomy.

The red flag here, So said, was that the two YAG laser capsulotomy procedures were done almost a month apart. 

What’s worse was that, after the 4th procedure on Fernando’s left eye, his doctor asked him to shell out an additional P3,500 ($77.28)* for an injection “para ‘di lumabo mata mo (so your vision won’t blur).” 

Wala naman akong hanapbuhay, hihingan pa ako ng P3,500. ‘Di na ako bumalik. Nung ‘di na ako bumalik, unti-unti na ngang lumalabo,” he said during Wednesday’s hearing. (I don’t have work, and yet they’re still asking P3,500 from me. I did not go back anymore. When I no longer went back, my vision started blurring.)

The extent of the damage on Fernando’s eyes was later discovered when he was examined at the Philippine General Hospital. 

Nung tiningnan ako ng 4 na doktor, sabi nila sa akin, iisa ang finding nila: ‘Nabutas ang iyong iris sa operasyon mo. May butas ang iris mo, ‘di na natin p’wedeng magamot,'” he said. 

(When 4 doctors examined me, they all said the same thing: ‘There’s a hole in your iris because of your operation. There’s a hole in your iris that we can no longer treat.’)

‘Scam’

Dr Minguita Padilla, the head executive staff of the health secretary and chair of the Eye Bank Foundation of the Philippines, said a YAG laser capsulotomy – one of the most abused procedures – can be dangerous for the patient if done too soon.

Ang pattern na nakikita, at sinasabi sa amin ng mga pasyente, kung minsan pagkatapos pa lang ng operation, sinasabi na sa kanila: ‘Bumalik ka para i-laser kita,'” Padilla explained. 

(The pattern we are seeing, and some patients told us this, that sometimes, right after an operation, they are immediately told: “Come back so I can do a laser procedure on you.”)

She added: “Parang pinepredict mo na magkakakomplikasyon siya, which is a long-term complication…. In other words, it’s already a scam, this is definitely a scam if the doctor tells the patient that.

(It’s as if you’re already predicting that a complication would occur, which is a long-term complication…. In other words, it’s already a scam, this is definitely a scam if the doctor tells the patient that.)

After they found out about this “scam,” PhilHealth decided to no longer pay claims for YAG laser capsulotomy procedures done less than 6 months after a cataract surgery. (READ: Harsher law needed to prevent PhilHealth claims fraud – Guingona)

PhilHealth is investigating top 10 ambulatory surgical centers (including Borough Medical Care Institute and Pacific Eye Institute) claiming for cataract procedures after they discovered a “very conspicuous rise” in claims which also coincided with complaints from patients.

Removal of cataracts ranked 4th among the top conditions and procedures PhilHealth paid for in 2014. This is equivalent to P3.7 billion ($81.70 million) out of the P78-billion ($1.72 billion) total benefit payments that year. – Rappler.com

*US$1 = P45.29

Eye close up image via ShutterStock

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Jee Y. Geronimo

Jee is part of Rappler's Central Desk, handling most of the world, science, and environment stories on the site. She enjoys listening to podcasts and K-pop, watching Asian dramas, and running long distances. She hopes to visit Israel someday to retrace the steps of her Savior.