COA’s questions on PhilHealth relate to both the living and the dead

PhilHealth

Philippine Health Insurance Corp. (PhilHealth) may have lost at least 22.72 million pesos last year because that amount was spent on paying premiums for 4,544 elderly members who had already died, according to a recent report by the Commission on the audit (COA) on the state health insurer.

The COA discovered that 8,156 deceased elderly PhilHealth members who should have been removed from its database were still there.

The deaths of the 4,544, or 55.71% of the elderly who died, were recorded in 2019. However, they were still included in billings to the Department of Budget and Management (DBM) for 2020, “which resulted in an oversubsidy from the national government amounting to P22.72 million, ”the COA said.

The state auditor said PhilHealth had “weak and weak” controls in its data collection after learning that 0.013% of the 6,235,438 registered seniors had already died.

This weakness exposes the state health insurer to “the risk of generating inaccurate / unreliable data and possible payment of fraudulent claims,” ​​the COA said.

COVID-19 tests

The COA also questioned the 3.375 billion pesos paid for COVID-19 testing using the reverse transcription-polymerase chain reaction (RT-PCR) method under PhilHealth’s Interim Funding Mechanism (IFM).

State auditors said disbursements did not comply with IFM, PhilHealth and emissions provisions regarding the Department of Health’s COVID-19 testing benefit packages and data ( DOH). “These disbursements could be considered unfounded allegations, unlike Presidential Decree No. 1445 (the government’s audit code),” the COA said.

He cited at least one case where PhilHealth gave 100 million pesos to a contractor as an advance payment, which is prohibited by the code unless approved by the president.

These findings were among those contained in the report released by the auditor last week, which found that payments of 14.97 billion pesos made under PhilHealth’s Interim Reimbursement Mechanism (IRM) were without legal basis. .

Questionable payments for premium subsidies for the elderly and COVID-19 testing amount to nearly 3.4 billion pesos more from state health insurer funds.

Overpayments

State auditors said the number of older people who died still in the PhilHealth database and the resulting government overpayments could be greater.

The audit body discovered the shortcomings after a review of DBM’s 2020 billing of 31.177 billion pesos covering 6,235,438 registered seniors, each with a premium of 5,000 pesos.

Only 18 responded

Under Republic Law 11223 or the Universal Health Care Law, the government will subsidize the PhilHealth premium of a Filipino who is unable to pay. This includes the registration of all seniors not covered by another category of PhilHealth membership.

With the Philippine Statistics Authority reporting in May 2020 that there were 12,336,355 Filipinos aged 60 and over, DBM figures indicate that PhilHealth accounted for the premiums of 50% of the country’s senior population. The COA asked 69 PhilHealth accredited hospitals for a list of deceased patients for 2020, but only 18 responded.

This led to the discovery of 8,156 elderly members of PhilHealth who were deceased but still in its database.

The COA said the figures given by the 18 hospitals represented only 1% of the total of PhilHealth’s 1,201 accredited hospitals and did not include people who died outside of hospitals.

“Thus, the possibility that a significant number of deceased elderly people may not yet be entered into the PhilHealth member database, given that only a percentage was taken into account in the team’s validation, to the detriment of the national government which subsidizes the premium contribution ”, he added. .

After PhilHealth agreed with state auditors to update its database, the COA found that 2,187 out of a sample of 2,344 deceased elderly members were still labeled “active instead of dead. “.

This meant that the status of PhilHealth members was still not updated.

State auditors were unable to verify whether the information in the database was reliable, pointing out that “poor data quality tends to produce inaccurate reports or analyzes which lead to poor decision making “.

Under the Bayanihan law

Several errors were also discovered in the data encoding of registered elderly people, such as misspelled names, incorrect names encoded, spacing errors, non-encoding of first or second names, encoding of names. initials of the middle name instead of full middle names, errors in encoding dates of birth. , erroneous gender entries, duplicate entries and others.

The COA said part of the 3.375 billion pesos paid for 950,144 RT-PCR tests was the advance payment of 100 million pesos to a contractor, who was not identified in its report.

The money was released in May 2020, a month after the entrepreneur and PhilHealth signed a Memorandum of Understanding on the use of IFM under Republic Law 11469, or Bayanihan to Heal. as One Act.

But the COA questioned the disbursement.

“In the absence of evidence demonstrating that the advance of funds made to the entrepreneur has a legal basis or a posteriori approval from the President of the Philippines justifying the exemption from the proscription against advance payment, the same was without legal authority and could be considered illegal spending, ”the audit body said.

It was not stated in the COA report how many of the nearly one billion tests were accounted for by the unidentified contractor.

State auditors added that “the merits and occurrence of IFM claims amounting to 3.375 billion pesos could not be reasonably established.”

Empty, incomplete

Indeed, many Case Information Forms (CIF) submitted for testing contained empty fields or incomplete details, as well as inconsistencies and gaps in the validated row list or summary of test results. Payments were also made before the required CIFs were submitted, the COA said. .

He said that some disbursement vouchers also did not include documents that could have determined the composition and relevance of any payment adjustment or deduction due to problems in the submitted forms, “which would indicate that the requests were not made. ‘have not been fully validated by PhilHealth prior to payment, “COA said.

He said releasing funds for properly completed CIF-free RT-PCR testing was contrary to the IFM’s and PhilHealth and DOH’s broadcasts on COVID-19 test packages and data. The lack of full CIFs also “prevents the audit team from determining the merits of the claims.”

Revalidate payments

PhilHealth was requested to submit properly completed CIFs on all payments and documents supporting deductions, otherwise disbursements would be suspended during the audit. He has also been asked to revalidate payments to ensure only valid tests are paid, to deduct overpayments from future claims, and to ensure payments are accompanied by full documentation.

PhilHealth said it has revalidated and identified 5,374 claims with deficient records, and “adjustments in the amount of 18.809 million pesos have already been deducted from outstanding debts to the contractor for these claims.”

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