“Ghost Dialysis”: Inquirer Breaks Story on PhilHealth Fraud

CHEERS TO the Philippine Daily Inquirer for a three-part series that exposed the fraudulent practices in the Philippine Health Insurance Corporation (PhilHealth). The report traced the use of ghost billings by the WellMed Dialysis Center, a healthcare facility in Novaliches, Quezon City which provided medical treatments to PhilHealth clients.

The first of the series worked with sources who had formerly worked with WellMed, recalling the schemes used to defraud the government. Former employees and whistleblowers Edwin Roberto and Liezel Santos said the practice had been going on since March 2016.

Roberto described the scheme as “ghost dialysis,” in which WellMed claimed payments from even after the patient had died. WellMed also filed claims on behalf of living patients, adding to the number of dialysis treatments than actually provided, or collecting for dialysis treatment when patients availed of other medical services.

In part two, the Inquirer explored the loopholes in the operations of the PhilHealth system. Citing PhilHealth officials who spoke under conditions of anonymity, the report zeroed in on the failure to review the “all-case rates” (ACR) payment mechanism, which sets a standard rate for a particular disease, and the instances of “upcasing” or describing a more severe illness than what had been diagnosed, leading to over-billing and defrauding PhilHealth of up to billions of pesos.

Concluding the series, the third part looked into the supposed existence of a “mafia” within PhilHealth whose members enabled and protected the fraudulent practices. According to the PhilHealth officials who spoke to the Inquirer, the so-called “mafia” prevents reforms in the agency.

Since their initial expose, the Inquirer has continued to produce follow-up reports on the matter, with other news organizations following suit.

The investigative reports have stirred up many other issues, pressing authorities to plug the loopholes in the PhilHealth operations. If no action is taken, the recently passed Universal Healthcare Law, which seeks to expand PhilHealth’s coverage and services, will be open to the same abuse. Media should try and prevent this by keeping vigilant watch over the government’s response to this expose.