NBI steps in as PhilHealth admits to bleeding P200 million a year in Northern Mindanao

CAGAYAN DE ORO CITY, Philippines – The National Bureau of Investigation (NBI) in Northern Mindanao has started an investigation into suspected fraudulent health insurance claims that cost the Philippine Health Insurance Corporation (PhilHealth) an estimated P200 million annually in the region alone.

Nationwide, PhilHealth said at least 9,525 fraudulent claims have been identified. These involve misrepresentation of medical cases, and claims made concerning the COVID-19 pandemic.

There could be more undetected fraudulent claims in the region involving hospitals and other healthcare institutions, physicians, PhilHealth insiders, and fixers.

Lawyer Ian Alfredo Magno, PhilHealth legal division head for Northern Mindanao, said PhilHealth has been paying an average P4 billion a year in insurance coverage in the region, and “statistically, 5% of those claims are fraudulent.”

Five percent of P4 billion translates to an estimated P200 million.

PhilHealth, he said, has so far suspended the accreditation of six hospitals in Northern Mindanao due to alleged fraudulent claims.

NBI director for Northern Mindanao Patricio Bernales Jr. said PhilHealth officials in the region have agreed to give it access to documents about health insurance coverage claims.

“The NBI will be working hand-in-hand with PhilHealth in the investigation of these criminal acts. We will endeavor to ferret out the truth, and we will definitely be filing (criminal) cases,” Bernales said.

Delio Aseron II, PhilHealth regional vice president, said they also asked the NBI to investigate the PhilHealth regional office itself because “it is hard (for us) to investigate ourselves.” 

On Friday, April 8, the NBI and PhilHealth in the region signed an agreement that allowed the Bureau to check PhilHealth’s records, and speed up the investigation into the allegedly fraudulent claims.

Since 2019, the PhilHealth regional office has filed 183 administrative cases for fraudulent claims. Magno said 113 of the cases were filed in 2019, 35 in 2020, 28 in 2021, and seven in 2022.

Many of the cases involve upcasing or instances when the patients’ health conditions are deliberately misrepresented so that PhilHealth-accredited institutions and physicians could claim more health insurance coverage funds.

Officials said an initial investigation showed that there were many instances when Philhealth-accredited doctors signed documents on patients they did not treat just so that insurance claims can be made.

But no criminal case has been filed against suspects because the PhilHealth central office has yet to decide on the administrative cases, according to Magno.

“Until decided by PhilHealth central office, we can’t say with finality that these are fraudulent acts,” Magno said.

Aseron said PhilHealth would not hesitate to suspend more accreditations the moment investigators find evidence that they have filed fraudulent claims.

Without accreditation, they will lose their income because it would be unlikely for patients to go to hospitals without PhilHealth accreditation. Aseron said some 40% of the hospitals’ incomes come from insurance coverage payments.

“These funds are contributed by our members through their hard work, and we want to ensure that these are kept safe. We would like to protect the money remitted by our members. We are warning those who take advantage of our program,” Aseron said. – Rappler.com