TUGUEGARAO CITY, Philippines- The Philhealth regional office in Cagayan Valley is now investigating of what appears to be a syndicate that has already cost the agency an initial P2.2 million.
Oscar Abadu Jr, Philhealth regional vice president, said in their initial investigation, they found out that the Tuguegarao City People’s General Hospital (TCPGH) hosted at least 135 alleged ghost claims.
The alleged ghost claims were reportedly paid by Philhealth in the years 2015 and 2016. In 2016, about P930,000 were claimed through fraudulent documents.
Worse, according to Abadu, the amount could still rise as they are yet to finish the investigation.
How did this happen? How did the system allow the people involved to do this?
Mastermind
During the interview, Abadu refused to name those involved in the scam, including those whose name was used in the fake claims.
But a copy of the result of the investigation initiated by Dr. Ray Dulig, head of TCPGH, was acquired by Forum from a credible source.
The investigation showed that there was connivance between an employee named as Marites Attaban and a visiting physician.
Attaban is in charge of “accepting and verifying documents submitted by patients to support Philhealth Claims and accessing PhilHealth portal for PhilHealth Benefit Eligibility Form (PBEF), and completion and finalization of claim documents for submission to PHIC for payment.”
In an interview, Dulig said the function and work of Attaban made the modus possible.
However, Attaban, according to Dulig, would not own up to masterminding the scam.
Dulig said the discovery of the scam was accidental when Ma. Socorro Manibug, an employee of the hospital in charge of the Billing and Claims Section, noticed a discrepancy in the claim form of patient Gilbert Macatuggal.
Attaban processed Macatuggal’s claim. Macatuggal later claimed that Attaban connived with him to claim his PhiliHealth benefits by faking the documents.
“Initially, they denied. But due to the fact that they didn’t answered in the affirmative, I wrote a memo requiring them to explain within 72 hours why they should not be suspended,” Dulig said, stressing that they were the one who discovered the anomaly, not PhilHealth.
An “exhaustive” investigation of the hospital, according to Dulig, led to the discovery of other fake claims, other than of Macatuggal’s.
“I investigated them. I reviewed all the documents. Lahat ng mga [anomaly], it’s hard to discover. It seems everything is in order, ‘yun pala, ‘yung isa ay scammer. Scammer eh, magaling,” Dulig said. He is referring to Attaban.
“Actually, she is not part of the organizational structure of the city hospital. She is only a detailed employee, and mind you, one employee wreak havoc in the hospital with the connivance of a private doctor, a visiting doctor,” Dulig added.
He said Attaban was also involved in an anomaly in Cagayan National High School, where she previously worked as teacher.
Attaban initially denied, but Dulig had reportedly pressed her after presenting evidences and testimonies of Macatuggal and the conniving doctor.
“How can she deny eh umamin ‘yung pasyente. See, how’s the catch,” Dulig said.
In his report, Dulig said Macatuggal confirmed he was not admitted in the hospital, making him already illegible for a PhilHealth benefit claim.
Macatuggal, however, initially denied that he knows Attaban. But he later admitted that Attaban reached out to him.
“Eh ma’am, ari na kan kari medamay nu magergo na,” (Ma’am, would I be not liable if I speak?) Macatuggal asked the investigating panel.
Macatuggal disclosed that Attaban promised him half of the PhilHealth claim. He said Attaban only asked for his PhilHealth number for processing.
He added that prior to his scheduled testimony to authorities, Attaban reportedly texted him not to go to the investigating because she would only deny what he would have to say.
Modus
So how was it done? Abadu said the modus is simple.
A non-hospital employee would go around the city to look for possible members of PhilHealth to be used for the scam. He/she is called the “shopper.”
The shopper targets the “poor” members of PhilHealth, asking them if they want to have money in an easy way. These families are called the “willing victims.”
Abadu said these PhilHealth members might have agreed to be part of the scam because of extreme poverty and the promise of the scammers of “good money.”
Upon agreement, the PhilHealth member gives the shopper his/her membership identification (ID) number.
After that, the process within the hospital begins.
Investigations showed the conniving doctor had pre-signed the PBEF. This will make the fake claimant appear to have been admitted in the hospital, thus, eligible to receive PhilHealth benefits.
As of posting, the pre-signed PBEF had already been surrendered to the PhilHealth for disposal.
The form is then processed by the conniving hospital employee. She is called the “insider clerk,” which in this case is Marites Attaban.
Abadu said Attaban made as if the fake claims are “valid” as she randomly inserted it to the legitimate claims.
“They made it appear that they bought medicines outside,” Abadu said, adding that the expenses outside the hospital will be subject for reimbursement in the hospital, as paid by PhilHealth.
Sharing
The sharing is also simple, according to Abadu.
He said the highest amount claimed was P28,000, a usual benefit for patient admitted for Cardio-vascular Accident (CVA).
In this case, Abaddu said the professional fee for the involved is P8,400 for each qualified claim. For the question how much went to the inside clerk and the PhilHealth member, it depends on how much they claim to have spent outside the hospital.
Abaddu said one witness told them he received a check of P9,000 at the Tuguegarao City Hall Treasury Office for his “benefits claim.”
The witness reportedly admitted he was given P4,000 and the rest went to the conniving employee of the hospital.
In his report, Dr. Dulig said of the more then P2 million alleged fake claims, about P844,000 went to conniving doctor.
When he confronted the doctor, Dulig said: “He told me, [Attaban] used me, sir. Used you? You are the doctor! How can you be used by a mere employee?”
Dulig said Attaban was forced to resign and the doctor was suspended pending investigations.
Denied
After discovering the scam, Abadu said they decided to deny TCPGH the accreditation to host PhilHealth members.
In an advisory, Abadu said they have denied TCPGH application “due to lawful and justifiable grounds.”
“Henceforth, all PhilHealth claims covering confinements beginning January 1, 2017, filed by or in behalf of TCPGH, shall be declined for processing until such time the accreditation of TCPGH will be renewed,”Abadu said.
The denial of TCPGH’s PhilHealth accreditation will hurt the poor, Abadu admitted, saying most of the poor PhilHealth members usually go to TCPGH.
“Definitely, mahirap na tanggapin na apektado an gating mahihirap na miyembro. Pero it also our part of our responsibility to take care because we are the managers of the National Health Insurance Fund,” Abadu told Forum.
Forum tried to reach Tuguegarao Mayor Benben De Guzman but received no response. Calls were also unanswered. -Northernforum.net
TCPGH photo courtesy of Taga Tuguegarao Ka Kung Facebook network.
