PhilHealth coffers bled over P15 billion due to fake pneumonia claims: Quimbo

ABS-CBN News

Posted at Aug 13 2020 03:56 PM

MANILA — The Philippine Health Insurance Corp (PhilHealth) lost as much as P15.4 billion from its coffers from 2014 to 2018 over schemes of falsifying pneumonia claims, Marikina Rep. Stella Quimbo said Thursday, as lawmakers continue to probe alleged extensive corruption within the agency. 

In a statement, Quimbo detailed the extent of fund leakages due to supposedly fraudulent PhilHealth claims for the respiratory illness, whether due to ghost claims from non-existent pneumonia patients or "upcasing."

Upcasing refers to the alleged collusion between hospitals and PhilHealth, with the facility submitting claims for pneumonia—amounting to P15,000 to P32,000 for each patient, depending on the severity— even if the patient simply had a cold or cough.

Quimbo estimated that in 2018 alone, fraudulent pneumonia claims cost PhilHealth over P3.6 billion, which, she said, could have been used to fund medication and hospitalization of coronavirus-stricken Filipinos. 

"On the average, PhilHealth paid P14,445 per claim in 2018, hence, the value of ghost and upcased claims is estimated at P3.6 billion in 2018... This amount, if not lost by PhilHealth, would have been sufficient to fund hospital admissions for PhilHealth’s total projected COVID-19 cases for 2020," the lawmaker said. 

Quimbo said that in 2018, the number of PhilHealth claims for pneumonia totaled 757,266, or 253,382 more than the estimated number of pneumonia patients based on the Department of Health's morbidity data. 

"In short, mas madami pa na sumingil sa PhilHealth para sa pneumonia kumpara sa bilang ng DOH ng nagkaroon ng pneumonia," Quimbo said.

(In short, there were more claims for pneumonia from PhilHealth than the DOH count of those who had pneumonia.)

Quimbo came up with the figures by subtracting the morbidity data of DOH from the actual pneumonia claims that PhilHealth paid for. 

Earlier this week, Sen. Imee Marcos in a Senate probe alleged that upcasing of pneumonia claims remained rampant within the agency, as she cited reports from local government units. 

The House of Representatives, the Senate, as well as an inter-agency task force created by the President are simultaneously conducting investigations into alleged irregularities in PhilHealth, including overpayments to hospitals and overpricing in procurement.

- report from RG Cruz, ABS-CBN News