54 more hospitals under investigation for fraud Codes: C2 Author: Jerry Esplanada Source: Philippine Daily Inquirer Date Published: 02/19/02 Starting Page: internet edition LAST Nov. 22, an inspection team from the Philippine Health Insurance Corp. (PhilHealth) made an unannounced visit to the Januaria Marcial Memorial Hospital in Banga town, in South Cotabato province in southern Philippines. In the 50-bed hospital, the team found more than a hundred pages of fabricated claim forms and other documents with false entries. "The team made the surprise inspection on Nov. 22 but some of the dates on the forms were already Nov. 25. The same forms were filled up by persons who (had) yet to be confined in the hospital," said lawyer Jay Villegas, head of PhilHealth's Fraud Prevention and Detection Unit (FPDU). When the team tried to confiscate the documents, however, hospital officials refused. "Instead, they set the forms on fire," Villegas said. "We have video and photos of the incident." Januaria Marcial is one of many health care providers on the "watchlist" of PhilHealth, a state-run insurance firm administering the National Health Insurance Program for both private- and public-sector employees. On Dec. 23, PhilHealth suspended the hospital's accreditation. (The INQUIRER tried but failed to reach Dr. Elizabeth Bayuga, the hospital's medical director, for comment.) The FPDU is preparing charges of fabrication or possession of fabricated forms and supporting documents, among other violations of the National Health Insurance Act of 1995, against the hospital. Similar charges are being prepared against the Leona Lim Memorial Hospital, in the town of Valencia in Bohol province, in the central Philippines. A PhilHealth team that visited the 70-bed health care establishment early this month found more than 1,000 pages of allegedly fabricated forms and supporting documents with false entries, Villegas told the I-Team. Contacted by telephone, Leona Lim Memorial Hospital administrator Jorge Buslon declined to comment on PhilHealth's findings. Claims by so-called "ghost patients" are not the only way PhilHealth loses hundreds of millions of pesos every year. There are also needless extensions of the period of hospital confinement, deliberate post-dating of claims, filing of double or multiple claims, and fabrication of claim forms and supporting documents. Some hospitals fraudulently extend the period of a patient's confinement by continuing to write entries in the doctor's order, nurse's notes and observation charts after a patient has been discharged. PhilHealth is investigating the following 19 hospitals for allegedly fraudulent extension of patients' confinement periods: · Ilocos Training and Regional Medical Center in San Fernando City, La Union; Governor Roque Ablan Sr. Memorial Hospital in Laoag City; Peneyra Clinic and Hospital in Lal-lo, Cagayan; Doctor Ester Garcia General Hospital in Cauayan, Isabela; Primo Gaffud District Hospital in Echague, Isabela; · Malolos San Vicente Hospital in Malolos, Bulacan; San Juan District Hospital in San Juan, Batangas; Ma. Estrella General Hospital in Calapan, Oriental Mindoro; Camarines Norte General Hospital in Daet, Camarines Norte; Antipolo District Hospital in Antipolo City; · Armed Forces of the Philippines Medical Center, Philippine National Police Hospital, St. Luke's Medical Center, Philippine Orthopedic Hospital, University of Santo Tomas Hospital, Olivarez General Hospital, Christ the King Maternity and Lying-In Hospital, St. Victoria Hospital, and Manila Doctors Hospital, all in Metro Manila. Leo Tubaņa, administrator of the 25-bed Primo Gaffud District Hospital in Echague, Isabela, denied the charge. "In this government hospital we serve the people with sincerity and dedication," he said. "We don't resort to fraudulent activities." Some hospitals also post-date claims, Villegas said. "Again for the purpose of claiming payment, a hospital files a claim for payment of services rendered not within 60 days from the date of discharge of the patient. They do it by altering dates just to conform (with) the 60-day prescriptive period," he said. "Hospitals who furnish false information or (are) found preparing claims with false entries or refuse to give benefits due to a PhilHealth member, as well as those who charge patients for medicines or services which are legally chargeable to and covered by the program, are also liable to various penalties," Villegas added. PhilHealth records show that at least 33 hospitals in the Philippines are under investigation for allegedly filing double or multiple claims. In Metro Manila, the list includes the Philippine Heart Center in Quezon City, which faces nine administrative cases. But "there was no intention to cheat (PhilHealth)," Heart Center director Ludgerio Torres explained. "It must have been clerical errors committed by our billing people. I've forwarded the cases to our lawyer." Four cases are pending against the Makati Medical Center, and the respective hearings are ongoing, said Vita Guinto, Medicare head of the prestigious 600-bed hospital. Guinto also blamed "clerical errors" for the trouble the hospital was in. She said it was "unthinkable for a hospital like Makati Med, one which advances millions of pesos in Medicare claims, to resort to fraudulent claims just to make some money." "Our office makes sure no irregularities are committed in the filing of Medicare claims. But sometimes clerical mistakes are committed along the way," Guinto told the INQUIRER. Also charged with four counts of multiple filing of claims is the De Los Santos Medical Center in Quezon City. Other hospitals charged with multiple claims include the following: · Jose Reyes Memorial Medical Center and University of Perpetual Help- Rizal Medical Center (three counts each); · University of Santo Tomas Hospital, University of the East-Ramon Magsaysay Memorial Medical Center, Mary Johnston Hospital, Ospital ng Maynila Medical Center, Unciano General Hospital, and Dr. Jesus Delgado Memorial Hospital (two counts each). · Medical City, Cardinal Santos Medical Center, East Avenue Medical Center, Fort Bonifacio General Hospital, Family Clinic, Children's Medical Center and General Hospital, National Kidney and Transplant Institute, John F. Cotton Hospital, St. Jude General Hospital, FEU-Dr. Nicanor Reyes Medical Foundation, and Our Lady of Lourdes Hospital (one count each). Also facing similar charges are the Ifugao Provincial Hospital in the Cordillera Administrative Region; Central Luzon District Hospital in San Vicente, Tarlac; Tiong Bi Hospital in Bacolod City; Angel Salazar Memorial General Hospital in San Jose, Antique; and the Zamboanga Doctors Hospital in Zamboanga City. Sister Normita Guevara, administrator of the Daughters of Charity-run Mother Seton Hospital in Naga City, said the 100-bed hospital had settled the double-claims case PhilHealth filed against it, but records at PhilHealth's head office in Pasig City showed otherwise. "It wasn't a fraudulent claim. There's a simple clerical error in the claims form," Guevara added. PhilHealth had earlier meted a three-month suspension on the B.A. Hospital Inc. in Meycauayan, Bulacan, for filing double claims. A hospital representative admitted the error, saying they were "not properly informed that double filing is no longer allowed." B.A. Hospital lawyer Bonifacio Tavera Jr. apologized for his client's "ignorance". Several hospitals nationwide have also been charged by PhilHealth with padding of Medicare claims. These include the following: · Calamba Doctors Hospital in Parian, Calamba, Laguna, Jose Reyes Memorial Medical Center in Manila; Holy Infant Clinic in Tuguegarao City; Nueva Ecija Good Samaritan General Hospital in Cabanatuan City; G. Gonzales Medical Clinic in Tiwi, Albay; · Zamboanga Doctors Hospital in Zamboanga City; Pagadian Community Hospital in Pagadian City; San Pedro Hospital of Davao City; and the Samal District Hospital in Samal, Davao del Norte. Why do some hospitals resort to fraudulent claims? PhilHealth insiders blamed "criminal minds and the palusot or short-cut mentality of some hospital owners and doctors." Lawyer Valentin Guanio, head of PhilHealth's legal services group, said "maybe all of the above. But it's obvious, it's money they are after." "There are doctors with criminal minds," said Dr. Bu Castro, secretary general of the 50,000-member Philippine Medical Association (PMA). "There are also doctors who are material gains-oriented, short of saying mukhang pera. And because of their primary concern which is money, they resort to fraudulent activities. "These things really happen. In every organization, there is always a bad egg and the PMA is no exception. Here, we won't think twice about expelling bad eggs from the PMA. That's the most we can do. We're protecting the profession." The PMA, he said, is "aware of PhilHealth's charges against some of its members. Some of them are valid and we don't tolerate fraudulent activities." "Fraud cuts across any profession, whether they are lawyers, engineers or doctors," noted Dr. Francisco Duque III, PhilHealth president and chief executive officer. "I suppose in any profession there are snakes in the grass."