NBI files graft raps vs. 21 PhilHealth officers over ‘ghost’ dialysis claims

The National Bureau of Investigation (NBI) has filed graft charges against 21 officials and employees of the Philippine Health Insurance Corporation (Philhealth) for their alleged involvement in the processing of "ghost claims" by a dialysis clinic in Quezon City.

The new complaint is an offshoot to the claims of two whistleblowers who said WellMed Dialysis Center, the clinic they used to work for, was behind a fraudulent scheme that involved raking in payments from PhilHealth on behalf of already deceased patients.

The Department of Justice is already prosecuting one of WellMed's owners and the two former employees who revealed the alleged scheme for estafa through falsification of official documents. NBI officials said prosecutors refiled the previously dismissed case before the proper court last week.

This time, the NBI wants prosecutors to indict the 21 PhilHealth officers for graft and for violation of the National Health Insurance Act and to hold them liable for the administrative charge of gross inexcusable negligence.

The head of the PhilHealth's accreditation department and officers of the accreditation subcommittee (ASC) in the PhilHealth's National Capital Region (NCR) office were named respondents to the complaint, which was filed Tuesday and announced Wednesday.

The charges are based on the allegation that the accreditation subcommittee continued to process WellMed's claims for a time despite a finding by the PhilHealth's fact-finding department that the clinic had "committed fraudulent acts of filing benefit claims for dead individuals."

According to the complaint, WellMed's application for accreditation for 2019 had been approved by up to the regional vice president but that the finding of fraud triggered meetings, resolutions, and memoranda on whether this could lead to a denial or a withdrawal.

In May, the subcommittee allegedly resolved to continue processing WellMed's claims based on an official's memo that the clinic's accreditation had already been granted and that its withdrawal "should be supported by evidence establishing" that the clinic "is absolutely at fault."

But in the following month, another official directed the NCR office to temporarily suspend payments of WellMed's claims. "Payment to claims of WellMed continued until its temporary suspension on 13 June 2019," the complaint read.

"It must be emphasized that there is no law, policy or internal memorandum granting the ASC to act on issues other than from applicants for accreditation," it said, adding that the body "overstepped the bounds of its authority" by making a decision on the the withdrawal of accreditation and payment of claims.

"Being said, such acts are considered void. The negligence committed by the members of the ASC resulted to unnecessary payment of claims to WellMed," the NBI said.

The NBI also alleged that the PhilHealth's NCR office failed to periodically monitor WellMed's performance.

NBI Deputy Director Vicente de Guzman III said the new complaint only pertained to WellMed but that the bureau is looking into other health care providers. — BM, GMA News