Exorcising PhilHealth’s Ghosts

Atty Dodo Dulay

June 11, 2019
Manila Times

GHOSTS aren’t real. Or so they say. In the latest of a

string of controversies plaguing the Philippine Health
Insurance Corp. (PhilHealth), recent reports have
attributed the loss of billions of pesos of people’s
money to “ghost” patients.

According to whistleblowers Edwin Roberto and Liezel

Santos, former employees of the privately run WellMed
Dialysis Center and Laboratory Corp., the scheme
involved PhilHealth funds being claimed and released
for the dialysis treatment of dead patients. Yup, that’s
right.

Apparently, ghosts can get sick (and have to be

treated!). The issue has thrust PhilHealth back into the
national spotlight, albeit for all the wrong reasons. The
timing is especially worrisome, considering that
PhilHealth itself is the agency tasked with the
implementation of the recently passed Universal Health
Care Act (UHC Act). Understandably, the scandal has
cast serious doubt on the agency — how will it be able
to effectively implement such a complex and extensive
law like the UHC if it can’t even efficiently monitor its
current system? The answer seems to be that it can’t,
at least for now.

As a result of the scandal, President Rodrigo Duterte is

looking into reorganizing and reshuffling the entire
agency. The President wondered how funds could be
dispersed so easily without any (supposed) system of
checks and balances, and without any kind of
accountability whatsoever. He’s right. How could it?
Section 46 of the implementing rules and regulations of
Republic Act 7875 the “National Health Insurance Act”
provides for the time period within hospitals or clinics
may file reimbursements or claims for payment of
services rendered although this may be extended by
PhilHealth. It is healthcare providers (i.e. hospitals or
clinics) which should “submit the prescribed and
completely filled- up PhilHealth claim forms and other
documents required for processing.

This system of self-reporting, along with the extended

period to file claims, opens the claims process to abuse.
Whistleblower Edwin Roberto revealed that the scheme
is centered around Philhealth’s dependence on the
reporting by hospitals or clinics of the deaths of their
patients. Roberto said that “[i]f a patient died at home,
dead on arrival, or died in the hospital within 24 hours,
there is no need to submit any document to PhilHealth
to update and make claims. Because Philhealth is
unable to know if a patient has died, the facility
continues to charge and file claims.”

In simple terms, if PhilHealth does not know that a

patient is already dead, it will keep on paying for these
ghost treatments. Not only that. Other fraudulent
schemes have continued to run roughshod on
PhilHealth’s operations. Some of these schemes involve
the “padding” of expenses to make it appear that the
hospital or clinic incurred more than what was actually
spent.

Another is the claiming of unused benefits. For

example, a dialysis patient who only used up 40 of the
90 sessions he or she is entitled to under the rules,
opens up the remaining 50 (that is, the unused
sessions) to manipulation. If you put yourself in the
shoes of the patient, would you really care about the
remaining 50 sessions, if 40 sessions is all you actually
need? In case the patient will not use up all of his or her
entitled benefits, the remaining sessions may be
fraudulently claimed by the health care provider for
their own benefit.

No law or process is perfect. But as constructed at

present, the PhilHealth rules and processes leave a lot
to be desired. The problem was actually recognized in
the UHC Act, Section 4 (u) of which states that
“[u]nethical acts refers to any action, scheme, or ploy
against the NHIP such as overbilling, upcasing,
harboring ghost patients…” Principally authored by
outgoing Sen. “JV” Ejercito, the law aims to “[e]nsure
that all Filipinos are guaranteed equitable access to
quality and affordable health care goods and services,
and protected against financial risk.” Undeniably, the
implementation and success of the law will be heavily
dependent on whether PhilHealth gets its act together.

A lot of PhilHealth’s funding comes from enforced

contributions. And they will burden the public into
compliance for billions of funds to…go missing? To be
used to treat ghosts? This means billions of funds
wasted that could have been put to better use. This is
money that could have been used to fund people who
are actually sick, and not the ghosts that roam the halls
of PhilHealth and its accredited hospitals or clinics.

Aside from going after the perpetrators of the scam

(which by all means, we should do), we must be
proactive and focus on the upcoming UHC Act, which
will place a bigger administrative and financial burden
on PhilHealth. Immediately, that focus should be geared
towards improving the provisions of the implementing
rules and regulations of the UHC Act.
Legislators should take a cue from the recent
controversy to carefully design preventive mechanisms
for the better implementation of the UHC Act. This
requires revisiting the allocation of the 7.5 percent
administrative cost for implementing the program. An
improved reporting process, as well as a system of
review to check the veracity of claims, will go a long
way toward minimizing the misuse of funds.

As the President said, a system of checks and balances

must not only be instituted, but strictly followed. Stiffer
penalties should be considered. After all, these are
public funds we are dealing with, and any misuse of
public funds should be accounted for.

The UHC Act itself is groundbreaking legislation — the

first of its kind in the Western Pacific region. Despite its
laudable objectives, and the hard work put in by our
legislators, it runs the risk of being mishandled and
upended by the few who value their quality of life over
the health of their fellow Filipinos. Oh! The irony.