25 hospitals, 9 doctors flagged for fraudulent PhilHealth claims

25 hospitals, 9 doctors flagged for fraudulent PhilHealth claims

GENERAL SANTOS CITY – At least 25 hospitals and nine doctors in Region 12 (Soccsksargen) could face charges over alleged fraudulent practices and insurance claims with the Philippine Health Insurance Corp. (PhilHealth), an official said on Tuesday.

Dr. Hector Zenon Leonardo Malate, acting regional vice president of PhilHealth-Region 12, said this was based on the results of their fact-finding investigation on 40 claims that were earlier flagged by their benefits and administration.

He said their legal section has completed its probe and submitted the findings to their central office’s Fact-Finding, Investigation and Enforcement Division (FFIED).

“It (FFIED) will determine the possible administrative cases that would be filed against the concerned health care institutions and professionals,” he said in a press conference in Koronadal City.

Malate said most of the violations were for “misrepresentation, (claiming for) non-admitted patients, extending the period of confinement and multiple filing of claims.”

As of Nov. 30, he said their benefits and administration section has already referred a total of 7,802 claims, with 4,147 cases added since he assumed office in late October, for investigation.

He said 5,207 claims were so far resolved while 2,595 were still pending before their legal section.

In terms of collection and membership-related cases, Malate said 571 of the 656 cases they received were acted on by their legal section.

He said some 80 employers who faced complaints for non-payment of premiums of their workers have opted to settle while five are currently facing complaints before the prosecution offices.

For the claims involving coronavirus disease 2019 (Covid-19) cases, he said they denied 20 out of the 794 they received as of Nov. 30 for the treatment, community isolation, and testing packages.

He said 580 claims are currently in process, 190 returned for compliance of some deficiencies while four were so far paid.

Malate said the denial of the claims was based on the results of the mandatory medical pre-payment review for all Covid-19 cases.

He said hospitals are required to submit true copies of the clinical charts of the patients to ensure that they only cover the legitimate cases. (PNA)

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