ILOILO CITY – The Philippine Health Insurance Corp. (PhilHealth) has widened its investigation on irregularities in claims related to cataract operations.

PhilHealth Acting President and Chief Executive Officer Lorna Fajardo said they have sent investigators to communities where medical missions related to cataract surgeries have been held.

“People are coming out with information on similar practices. It looks like the modus operandi of some doctors and hospitals are being copied,” Fajardo in a telephone interview said.

In October, PhilHealth issued a circular stopping the payment of claims for cataract surgery during medical missions and through recruitment schemes.

It also filed administrative cases against four doctors and three hospitals in relation to irregularities in insurance claims for cataract surgeries.

The irregularities include the “padding” of claims of doctors and hospitals to maximize payments by including medicines and services that were not availed of by the cataract patients and the use of “seekers” to recruit patients for the surgeries.

The doctors are facing a total of 29 charges for padding claims, misrepresentation and violations of provisions of the PhilHealth warranties of accreditation and the Republic Act 7875 (National Health Insurance Act) before the PhilHealth's prosecution department.

Fajardo said if there is prima facie evidence against the doctors and hospitals, there cases will be referred to the arbitration department and to the PhilHealth board for decision.

She said some doctors and hospitals have been “playing” with and “gaining” from the PhilHealth rules and policies.

“They took advantage of the trust we gave them,” said Fajardo.

PhilHealth and the Philippine Academy of Ophthalmology this month entered into an agreement to help deter spurious claims and unethical practices in cataract surgeries.

The memorandum of agreement provides for closer coordination between the PhilHealth and PAO concerning claims for cataract operations.

Under the agreement, PhilHealth will coordinate with PAO in the resolution of issues arising from claims for cataract surgery patients recruited through medical missions or other recruitment schemes. It will also provide support to PAO in the investigation or verification of claims for cataract surgeries.

Fajardo said that they hope that, with the filing of cases and the closer coordination between PhilHealth and PAO, the irregularities will soon be totally stopped.*NPB

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