The Philippine Health Insurance Corp. (PhilHealth) has found a Bacolod City hospital guilty of fabricating claims for cataract surgeries conducted on patients recruited through medical missions.
In a 14-page decision dated September 16, the PhilHealth Arbitration Department found the Bacolod Our Lady of Mercy Specialty Hospital (BOLMSH) guilty of six counts of "padding of claims" and "breach of accreditation."
PhilHealth ordered the hospital to pay a fine of P10,000 fine for each count or a total of P120,000. It also meted a three-month suspension of the hospital's PhilHealth accreditation for each count or a total of 36 months.
The agency also ordered the denial of payment for the six claims found to have been padded or for the hospital to refund the health insurance agency if the claims have already been paid.
The order was issued by lawyer Darwin De Leon, Officer-In-Charge-Health Insurance Arbiter and approved by Lawyer Germain Lim, Vice President, OIC -Arbitration Department.
In a statement released by the office of Dr. Evangeline Johnson, BOLMSH chief executive officer, the hospital said the resolution is still subject to for a motion for reconsideration and not yet final and executory.
"Bacolod Our Lady of Mercy Specialty Hospital and its staff, nurses and doctors reserve their rights to seek due process in the proper legal forum, to bring out the truth and obtain justice," the hospital said in its public statement.
It said the hospital has been "subjected to false and baseless accusations" but will continue to receive and admit patients both members and non-members of PhilHealth.
Lawyer Jay Villegas, manager of PhilHealth's Fact-Finding and Administrative Investigation Department, said in a telephone interview that the hospital has until October 1 to appeal the ruling or it will become final and executory.
The hospital and several doctors are facing several other complaints for alleged padded claims before the PhilHealth.
The case stemmed from a complaint filed by the PhilHealth's prosecution department on January 7, 2008 concerning the PhilHealth claims of six patients who underwent cataract surgery.
The hospital had filed claims that it utilized oxygen and intravenous fluids during the surgeries on the patients.
But upon verification with the patients, PhilHealth discovered that no oxygen or IV fluids was administered at any time during their confinement.
The respondent had moved for dismissal of the complaints and questioned the authority of PhilHealth officials and employees who conducted the investigation to administer oaths to documents related to case.
It claimed that the complaint was "based on hearsay" and on "pre-fabricated statements."
The hospital maintained that its claims were legitimate and insisted that oxygen and IV fluids were used. It presented affidavits of attending physicians and nurses to support its defense.
The hospital also submitted affidavits of three of the patients which refuted their earlier statements given to the PhilHealth investigating team.
In its decision, the arbitration department affirmed its authority to investigate and prosecute the complaint as well as the authority of PhilHealth personnel to administer oaths to the patients' affidavits.
PhilHealth gave credence to the statements of the patients given to investigators rather than the affidavits submitted by the hospital.
"In the instant case, we find the evidence of the prosecution more credible that must be accorded greater evidentiary weight," according to the decision.
It said the sworn statements of the patients given to investigators are "clear and unambigious in their declaration that oxygen and IV fluids were not given to them."
Philhealth noted that the sworn affidavits of the three patients submitted by the hospital were undated and not notarized. It also observed as suspicious that the statements were "identical in all details" including the words used and every detail.
It cited Supreme Court jurisprudence that "affidavits of recantation can easily be secured from poor and ignorant witnesses of monetary consideration or through intimidation, hence its is oftentimes frowned upon and its veracity suspect."
PhilHealth last year launched an investigation on irregularities on claims related to cataract operations of hospitals and doctors in Western Visayas involving at least P390 million.
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.
A PhilHealth position paper said the patients are recruited and screened "in the guise of free medical outreach programs" through "recruiters-agents" sent out by ophthalmologists in coordination with the hospitals where the operations are performed.
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