How eye clinics 'syndicates' defraud PhilHealth

MANILA, Philippines – The Philippine Health Insurance Corporation found at least 6 health care facilities which made PhilHealth members undergo cataract surgery even without the patients' informed consent.

Through this "modus," alleged syndicates were able to claim bigger benefit payments for cataract removal, PhilHealth president Alex Padilla said during a Senate blue ribbon committee hearing on Wednesday, July 1.  

PhilHealth is investigating top 10 ambulatory surgical centers claiming for cataract procedures after they discovered a "very conspicuous rise" in claims which also coincided with complaints from patients. 

Removal of cataracts ranked 4th among the top conditions and procedures PhilHealth paid for in 2014. This is equivalent to P3.7 billion ($81.95 million)* out of the P78-billion ($1.73-billion) total benefit payments that year. 

PhilHealth has suspended the processing of claims of Pacific Eye Insititute-Makati and Quezon City Eye Center. Padilla said they will soon suspend payments for two other centers. 

Common breaches

Without naming the facilities, Padilla told senators on Wednesday that at least 6 of the 10 centers under investigation have committed 4 common breaches of the performance commitment they signed in order to be paid PhilHealth reimbursements:

1. "Seekers" and members solicitation

To date, PhilHealth has identified 26 "seekers" who entice PhilHealth members – especially seniors – to consult with the eye centers, only to undergo cataract surgery later on without their informed consent. 

To entice members, seekers who "act like syndicates" use phrases such as "lilinisin ang mata," "papakintabin ang mata," "lalagyan ng lente ang mata," and "libre naman."

"Many patients don't know they will undergo cataract surgery," said Dr Minguita Padilla, the head executive staff of the health secretary and chair of the Eye Bank Foundation of the Philippines.

PhilHealth's case rate for cataract removal amounts to P16,000 ($354.39) per eye. Based on the investigation, seekers can get as much as P2,000/eye ($44.3) from surgeons, and P6,300/eye ($139.54) from the eye center in exchange for bringing patients.

2. Violations of standards of care

Some patients brought in by seekers were not advised for a followup checkup within 24 to 48 hours after a cataract surgery.

Without the check-up, doctors placed the patients at higher risk of suffering from complications that could lead to blindness or even removal of their eye.

"In fact, many of these patients were asked to come back weeks after just to undergo yet another procedure (laser) which in all indications [may] not have been necessary," PhilHealth said in a powerpoint presentation that was showed to senators. 

3. Violations of patient's rights

Some patients also did not have informed consent before the cataract surgery was performed. There were even patients with serious co-morbid medical conditions (example: poorly-controlled hypertension) who went through the surgery without a pre-operative clearance.

Some patients were even given misleading and incomplete information. In one facility alone, at least 20 of 29 patients were not informed of the type of Intraocular Cataract Lens implanted in their affected eye.

4. Lack of proper credentialing and privileging

"The 6 facilities audited do not have written guidelines in credentialing and privileging their affiliated health care professionals," PhilHealth said.  

There were also reported cases of actual fraud, such as fabrication of a doctor's credential, and a health facility offering "free services" like wart removal, only to file claims later on. 

After the Senate hearing, Alex Padilla said in an interview with reporters that they already limited the number of cataract surgeries a doctor can claim with PhilHealth. 

"The limit is 10 patients per day for every PhilHealth-accredited doctor. At most, a doctor can accommodate up to 50 patients per month. This is to prevent cases such as that of one doctor who, on his first year as an ophthalmologist, already filed claims worth P36 million," he said in a mix of English and Filipino. 

The next Senate committee hearing on the issue is scheduled next Wednesday, July 8. – Rappler.com

*US$1 = P45.15

Eye close up image via ShutterStock

Jee Y. Geronimo

Jee is part of Rappler's Central Desk, handling most of the world, science, and environment stories on the site. She enjoys listening to podcasts and K-pop, watching Asian dramas, and running long distances. She hopes to visit Israel someday to retrace the steps of her Savior.

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