Medical insurance fraud rampant?

Topic |  

Medical insurance fraud rampant?

Topic |  

Findings show that insurance fraud is rampant worldwide-and the Philippines is no exception.

A certain report said that due to fraud and operational inefficiency, Philhealth losses between 2013-2018 have been a whopping P 154-Billion that makes the P10-B Pork Barrel Scam look like peanuts. Philhealth is a major government health insurance agency providing medical insurance especially to indigents and senior citizens.

Due to the new sin and tobacco taxes, Philhealth’s budget has been raised to P68-B in 2019, 24% higher than in 2018. That is good news.

The worrisome point is that not all of the P154-B losses were management operating inefficiencies but likewise due to the prevalence of fraud of which the recent “ghost dialysis” cases of the Well-Med Medical and Laboratory could just be the tip of the iceberg.


Duterte has fired Dr. Roy Ferrer, PhilHealth President and most of the Philhealth Board of Directors; arrested and out on bail is Well-Med owner Bryan Christopher Sy while whistleblowers- former Wel-Med employees, Edwin Roberto and Liezel Aileen-de Leon, will likely be under the Witness Protection Program.

Busted in 2015 for forcing senior citizens to get unnecessary cataract operations (through agents for a fee) cost Philhealth P2-B. What takes the cake here is the Philippine Star columnist’s report that some “crooked politicians” had gotten a piece of the lucrative con game by being silent partners of certain eye clinics.

How “honorable” can these creatures descend, indeed?

Also lost are billions in the so-called “upcasing” of medical cases ( say from colds to pneumonia) for the health providers like hospitals, clinics and health center to charge higher fees and costlier medicines.

Now, for the “ghost dialysis”- one knows how much a dialysis procedure costs and note that Wel-Med is just one accredited health provider, among hundreds nationwide. And kidney is just one ailment. How big is the problem?

Given this state of alleged corruption among many accredited Philhealth health providers and the alleged connivance of a well-entrenched mafia in PhilHealth- can one begin to imagine the staggering illegal wealth pocketed by these hideous players now with deep pockets at the expense of the Filpino nation.


(The whistleblowers alleged that deceased Filipinos, as well as those with unutilized dialysis benefits, were used by the Wed-Med vultures for the “ghost dialysis.)


Will the other brave souls found among the employees and staff of other Philhealth accredited medical providers who have the same patriotic and moral zeal as witnesses Roberto and De Leon- please come forward, and be heroes in your own generation? And spill the beans on these malevolent crooks?

The culprits will be charged with estafa through falsification of public documents in violation of the Revised Penal Code- with years of jail sentence awaiting them.

Look at the list hereunder as provided by the PA Insurance Fraud Prevention Authority which of the medical providers -to one’s knowledge- have committed these fraudulent acts?


* billing for services and procedures never rendered or medical supplies never given by falsifying medical records

* using forged prescriptions from doctors’ offices and getting the medicines from pharmacies for insurance reimbursement


* performing unnecessary services for the purpose of financial gain

* misrepresenting non-covered treatments as a medical necessity

* falsifying a patient’s diagnosis to justify tests, surgeries or other procedures

*  billing each step of a single procedure as is it were a separate procedure

* charging a patient  more than the co-pay agreed under the insurer’s term

* bill diagnostic testing and interpretation actually are done by another firm

* recruiting low income, indigent patients to undergo an unnecessary exam with a falsified report of procedures never performed.

Usually benefitting from this undeserved  Philhealth insurance coverage windfall will be the owners of the family-owned medical providers or the board of directors and officers of more broadly-owned firms.

These abominable acts deserve wholesale condemnation from the nation-at-large coming as it does from services meant to save lives and alleviate people’s suffering and, then, financially endangering an institution like Philhealth, a major cog in providing wide health coverage for the Filipinos, many of who would underwise die without ever seeing a doctor and getting medicines.

Shame on all of them. The deepest recesses of hell await them.

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