SENATOR Sonny Angara has called for a strengthening of the anti-fraud mechanisms of the Philippine Health Insurance Corporation (PhilHealth) as part of the ongoing efforts to rid the institution of wastages due to corruption or inefficient systems.
Apart from pushing for the conduct of a special audit on PhilHealth funds following the most recent controversy faced by the state health insurer involving its allegedly overpriced information technology system and interim reimbursement mechanism (IRM), Angara noted the weaknesses in the firm’s anti-fraud mechanisms that has subjected its funds to abuse and misuse by some unscrupulous groups and individuals.
Angara said it is high time for PhilHealth to digitize its records and to utilize systems to validate membership claims just like what is being used by pension funds Social Security System and Government Service Insurance System.
This was part of Angara’s recommendations as contained in a letter to Senate President Vicente Sotto III as the presiding officer of the Committee of the Whole that recently conducted hearings on the controversies surrounding PhilHealth.
“They (PhilHealth) should likewise look into strengthening their manpower complement by hiring more medical reviewers, anti-fraud officers, data scientists, data analytics personnel, and even experts in artificial intelligence and big data,” Angara said in his letter.
The need to immediately digitize its records was highlighted during the Senate hearings where now resigned PhilHealth president and CEO Ricardo Morales disclosed that there are about 5,000 members who are 130 years old and that nobody knows if they are dead or alive.
Earlier this week, a television report noted how a senior citizen was told that he was already dead for almost four years already based on his PhilHealth member data record.
Angara has been pushing for the digitization of both the government and private sector as part of the national digital transformation program to improve efficiency in the delivery of services and prepare the country for the requirements of a rapidly changing world.
This is contained in Senate Bill 1470 of the proposed National Digital Transformation Act, which Angara filed last May 4.
In his letter to Sotto, Angara also reiterated his call for PhilHealth to immediately release detailed guidelines on the deferred liquidation of the COVID-19 IRM funds.
“PhilHealth, being a recipient of government funds, should ensure that these are paid, released and accounted for according to existing rules and regulations,” Angara said.
He also recommended an amendment of the Universal Health Care Act to include the mandatory audit of PhilHealth’s finances and to provide copies of the annual report to the Congressional Oversight Committee the Senate Committee on Finance and the House Committee on Appropriations.
A comprehensive review on PhilHealth’s implementation of All Case Rates claims payment scheme, including the re-calculation of the top 32 case rates for at least 90 percent of cases or claims filed was also recommended by Angara as part of his inputs to the drafting of the committee report on the hearings.
Angara previously noted how there were questionable case rates wherein some minor procedures or ailments would be paid more by PhilHealth than critical conditions.
This has also led to the practice of upcasing or when a health facility would upgrade certain ailments such as simple cough and colds to more serious conditions like pneumonia in order to collect bigger payouts from PhilHealth.
During the Senate hearings, Angara noted the claims for pneumonia recorded a sudden jump from less than P3 billion a year between 2009 and 2011 to P9.7 billion in 2015. From 2017 to 2019, claims for pneumonia have averaged at P10.5 billion a year.