The Philippine Health Insurance Corp (PhilHealth) lost as much as P15.4 billion from its fund reserves from 2014 to 2018 over falsified pneumonia claims, Marikina Rep. Stella Quimbo said.
In a statement, health economist turned lawmaker Quimbo ran down the the extent of fund leakages due to supposedly fraudulent PhilHealth claims for pneumonia, whether due to ghost claims from non-existent pneumonia patients or “upcasing.”
Upcasing means an alleged collusion between hospitals and PhilHealth, with the facility submitting claims for pneumonia—amounting to P15,000 to P32,000 for each patient, depending on the severity— even if the patient simply had a cold or cough.
In 2018 alone, she estimated that fake pneumonia claims cost PhilHealth over P3.6 billion.
“On the average, PhilHealth paid P14,445 per claim in 2018, hence, the value of ghost and upcased claims is estimated at P3.6 billion in 2018… This amount, if not lost by PhilHealth, would have been sufficient to fund hospital admissions for PhilHealth’s total projected COVID-19 cases for 2020,” Quimbo said.
Quimbo cited that in 2018, PhilHealth claims for pneumonia totaled to 757,266. This is 253,382 more than the estimated number of pneumonia patients based on the Department of Health’s morbidity data.
“In short, mas madami pa na sumingil sa PhilHealth para sa pneumonia kumpara sa bilang ng DOH ng nagkaroon ng pneumonia,” Quimbo said.
[In short, there were more claims for pneumonia from PhilHealth than the DOH count of those who had pneumonia.]
