MANILA — A scheme of "upcasing" simple cough into moderate or severe pneumonia in order to remit more benefits from Philippine Health Insurance Corporation (PhilHealth) remains rampant within the agency, Sen. Imee Marcos said Tuesday, citing reports from local government units in the Ilocos region.
'Upcasing' refers to the collusion between hospitals and PhilHealth, with the facility submitting claims for pneumonia—amounting to P15,000 to P32,000, depending on the severity— even if the patient simply had a cold or cough.
"Ito na 'yung upcasing... Uubo ka lang, may sipon-sipon ka lang, may sakit ng ulo kunwari, eh, biglang moderate risk pneumonia na kaagad," Marcos said in the Senate's probe on alleged corruption within PhilHealth.
"Upcasing na nang bonggang bongga ang nangyayari, from P2,000 to P3,000. O kaya, Tylenol, aspirin, biglang P15,000 na ang ibibigay."
The Senate has conducted an inquiry into alleged irregularities in PhilHealth, including a whistleblower's claim that the agency bled P15 billion-worth of funds that allegedly ended up in the pockets of several of its officials.
Marcos cited reports from local officials in Region 1, who supposedly claimed that pneumonia was not among the list of "reportable diseases," making claims for the illness "inauditable."
"Palibhasa hindi reportable ang pneumonia na siyang number 1 na claim, hindi ito na-o-audit. Totoo ba yon?" Marcos said.
PhilHealth senior vice president for health finance policy sector Israel Pargas said he would have to check Marcos' claim with the Department of Health (DOH).
"I think all infectious diseases po are part of reportable diseases. But I will have to confirm with the Department of Health (DOH), Pargas told Marcos.
Marcos likewise found suspicious the "uniform" annual claims for pneumonia ranging from P9 to P11 billion.
"Bakit ang taas-taas ng pneumonia? Halos uniform, taon-taon yung P10 billion? Wala bang epekto ang vaccination ng DOH?" she asked.
Pargas defended PhilHealth and said pneumonia claims go through a procedure called "medical prepayment" where they undergo review to make sure that they satisfy the agency's admissibility criteria.
"On the part of PhilHealth po, ang pulmonya, isa po yan sa ating mga claims na dumadaan sa medical prepayment... Iyung claims, nire-review muna ng mga doktor at tinitingnan kung pasok sa admissibility criteria," Pargas said.
This was not the first time PhilHealth was accused of processing bogus or questionable claims from medical facilities.
The National Bureau of Investigation (NBI) last year filed criminal complaints against 21 officials and employees of the state health insurance firm in connection with the alleged misuse of funds on "ghost" dialysis treatments.
WellMed Dialysis Center in Quezon City allegedly made payment claims for dead patients from PhilHealth from 2016 to 2018.