Fake claims, broken IT systems and controversial reimbursement mechanism revealed by 3 Philhealth officials

Duterte will not remove PhilHealth chief
Duterte will not remove PhilHealth chief

Another scandal has been revealed by three senior Philhealth officials who have also testified during the ongoing investigation by Task Force PhilHealth.

In a statement sent by the Department of Justice (DoJ) Usec. and Spokesman Markk Perete, among them Senior Vice President and Chief Information Officer Jovita Aragona, Corporate Secretary Jonathan Mangaoang and Acting Senior Manager of PhilHealth Fact-Finding Investigation and Enforcement Division (FFIED) Ernesto Barbado.

Aragona admitted that Philhealth’s current IT system could not detect fraudelent claims.

It mentioned the segment on the agency’s validation process is still being conducted manually.

Aragona explained that this is due to the failure of the relevant offices in Philhealth to determine the required internal control systems when Philhealth’s IT systems were being designed and developed.

Aragona clarified that the previous issue of the questionable purchases of Philhealth swiths was a transaction of the Philhealth office in the National Capital Region (NCR) and that there should be an investigation at such an office.

On Mangaoang’s side, the controversial Interim Reimbursement Mechanism (IRM) was first proposed in January 2020 to ensure the financial viability of hospitals and medical establishments in the event of emergency fortuitous events.

He said the Philhealth Board approved the IRM based on the opinion of the legal sector of Philhealth.

Mangaoang also confirmed the Board’s approval of the Philhealth Corporation’s Protest and Appeals Department’s recommendation to grant amnesty to hospitals that have been late in filing their claims for reimbursement since 2011.

Under the law created by Philhealth, reimbursement of clamis is not allowed beyond 60 days since the patient was discharged from the hospital.

Barbado, on the other hand, gives the Task Force a preview of the ghost or fake claims that were first investigated by FFIED.

“Aragona admitted to the inability of the current IT systems of PhilHealth to detect fraudulent claims. She identified the segments in the corporation’s validation processes that are still done manually. She attributed the current lack of validation mechanism in the corporation’s IT systems to the alleged failure of its relevant offices to specify their required internal control systems during the design and development of the IT systems. She likewise bared the corporation’s plans to develop a more sophisticated IT systems in the future. Aragona also clarified that the previously reported questionable procurement of switches was a transaction of the PhilHealth National Capital Region office. She called for an investigation to be conducted on said office. Meanwhile, Mangaoang stressed that the controversial Interim Reimbursement Mechanism (IRM) was proposed in January 2020 to ensure that hospitals and medical establishments remain financially viable in case of emergencies and fortuitous events. He noted that the PhilHealth Board approved the IRM based on an opinion issued by the corporation’s Legal Sector. Mangaoang likewise confirmed that the Board has approved the recommendation by the corporation’s Protest and Appeals Department to grant amnesty to hospitals that belatedly filed claims for reimbursement from 2011 onwards. The law that created PhilHealth renders ineligible for reimbursement a claim filed beyond sixty (60) days from the discharge of a patient. For his part, Barbado asked the Task Force to look into certain ghost or fake claims previously investigated by the FFIED. Before taking the testimony of these officials, the Task Force agreed to establish composite teams tasked to thoroughly investigate the Information Technology and Legal Sectors of the PhilHealth. The composite teams were directed to, among others, conduct further interviews, gather evidence, conduct audits, and report their findings to the Task Force, ”based on a statement sent by the DoJ.

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