OPINION | Digitalization will not reduce fraud in PhilHealth By Oscar P. Lagman, Jr. READ:
By Oscar P. Lagman, Jr.’s editorial of Nov. 11 reported that an Aboitiz Group-led consortium had submitted a P1-billion unsolicited proposal to digitize the claims process of the corruption-plagued Philippine Health Insurance Corp. . Aboitiz InfraCapital President Cosette Canilao said digitalizing PhilHealth’s claims process is a crucial step in addressing the problem of corruption and incompetence in the state health insurance company.
In health insurance moral hazard is multiplied threefold as the professional and the healthcare facility may be parties to the fraud. An example is the insured patient with a common cold asking a physician to recommend his hospital confinement. Doctors with slow or poor practices would be inclined to recommend confinement of individuals with feigned illness, and private hospitals with low bed occupancy rate would just be too ready to admit them.
When I was with a health insurance company, we received claims for whole families. We looked into the reason for this unusual sets of claimsled by a hospital in the province. Our inquiry revealed that when the children visited their father, a field employee of a geothermal company, in the hospital, they noticed he was served three good meals every day, slept on a comfortable bed in an air-conditioned room, amenities better than those in their own home.
The health insurance company I was with many years ago had 35,000 enrollees, 90% of whom were employees, the rest their dependents. An average of 6% of the insured filed claims during a one-year period, or an average of 2,100 claims were filed every year. Spread over 250 working days, the office received 8.4 claims each working day. There were three claims processors , each one a registered nurse with at least one year experience as a nurse in a tertiary hospital.
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