PhilHealth overbilled DOH by P12-B in health premiums in 2014 – COA report

The Philippine Health Insurance Corporation (PhilHealth) overbilled the Department of Health (DOH) by more than P12.384 billion for the government’s National Health Insurance Program (NHIP) for 2014, a Commission on Audit (COA) report revealed.

Based on a 2014 audit report published by COA on its website on Thursday, PhilHealth billed the DOH a total of P35.926 billion last year for health insurance premiums for 14,706,524 indigent families identified by the DOH and the Department of Social Welfare and Development (DSWD) to be included in the NHIP.

Under the program, each of the identified family should be enrolled in PhilHealth's program at a premium of P2,400 per year.

The allocation for the NHIP was included in the 2014 General Appropriations Act (GAA), the COA report noted.

Based on the state audit body’s records, the entire amount was billed to DOH and released by the Department of Budget and Management (DBM) to PhilHealth through a Special Allotment Release Order (SARO) No. 14-0008230 dated June 20, 2014.

The COA found that based on the PhilHealth database, only 9,546,439 indigent families had been enrolled into the program as of March 2014.

Yet the entire P35,296,657,000 was paid in full by DOH three months later.

The COA said this corresponds to a total of P12,384,203,400 in "excess health insurance subsidies” billed by PhilHealth from DOH.

"Compared with the 14,706,524 families given subsidy of P35,296 billion in the GAA, there was a difference of P12.384 billion, equivalent to the health insurance premium of 5,160,085 indigent families," the COA report read.

According to the report, PhilHealth management said that the excess in the amount received may be attributed to the difference in date of extraction of data.

"This justification, however, was not considered because in the bill sent to DOH, it was stated that'as of March 24, 2014, PhilHealth had covered 14,706,524 indigents and their families with a total NG share of P35.296 billion computed at P2,400.00 per member.'" the report read.

"However, data presented for audit showed that PhilHealth covered only 9,546,439 indigent and their families, 5,160,085 less than 14,706,524 stated in the bill. "

Overbilled in 2013

The COA further noted that in 2013, PhilHealth had also overbilled the DOH a total of P173.731 million in health insurance premiums

Thus, the total excess premiums paid by the DOH to PhilHealth now stands at P12.557 billion.

"The insurance premium subsidies granted to PhilHealth for the CYs 2013 and 2014 were observed to be in excess of the actual need because the enrollees reported by PhilHealth was less than the number of indigent families previously identified by the DSWD," the report read.

The COA also revealed that these excess amounts received from DOH were originally reported by PhilHealth in its books of accounts as "Income" instead of "Other Deferred Credits."

The audit agency said that it was only in December 2014 when the agency made an adjustment in its books and declared P173.371 million and P1.153 billion as "Other Deferred Credits" for 2013 and 2014, respectively. The COA said a total of P11.231 billion in excess health premium payments by DOH remain declared as "Income."

The COA said that based on the PhilHealth database record extracted by the agency's Task Force Informatics (TFI), the number of families declared by PhilHealth as enrolled to its health premiums as of December 31, 2014, stood at 14,226,091 from the original 9,546,439 declared in March of that year.

PhilHealth declared that it only has a balance of P1.153 billion from the payment it received from DOH.

Dummy data

However, upon analysis of the data submitted by the TFI, state auditors found that of the total indigent families declared by PhilHealth in its 2014 record, 8,503,270 families were actually enrolled this year, while only 5,722,821 families were enrolled in 2014.

"The identified indigent families of 8,503,270 enrolled in 2015 sourced from the TFI report are covered by budgetary appropriations for CY 2015 and shall not be included in the subsidy for CY 2014," the COA report read.

The COA further said that vital information of some of individuals declared as enrolled in the health premium were missing such as name of member, birth date and PhilHealth Personal Identification Number (PIN).

"In some instances dummy data were included, where in lieu of an individual’s profile only xxx appeared," the report read.

"The inconsistencies in the data/information supplied by management for the actual indigents enrolled for CY 2014 cast doubts on the reliability of the reports, the balances of the affected accounts and the correctness of the amount billed to DOH," the report added.

COA recommendations

GMA News Online tried to get a reaction from PhilHealth president Alex Padilla but he was not answering calls and text message.

The COA made the following recommendations to address the overbilling:

• "bill the DOH with the amount of health premium corresponding to the actual number of indigent families enrolled in the NHIP and not on the number of indigent families identified by the DSWD in 2011;"
• "prepare adjustment for the excess health insurance premium recorded as income to Other Deferred Credits in the amount of P11.231 billion."
• "deduct the excess subsidy in the future billings to DOH; and"
• "reconcile the number of enrolled indigent families in 2014 as shown in the report of TFI to the journal entries made."

The COA also suggested a review of the DOH’s billing requirements payment for insurance premiums of indigent families.

"There should be close coordination among DSWD, DOH and PhilHealth. It would be helpful if the DSWD provide PhilHealth with the list of indigent families for validation before submission to DOH for budgeting purpose," the COA recommended.

"With this linkage among the aforementioned government agencies, the discrepancy between the insurance premium subsidy and the actual premium of enrollees would be reduced significantly," the report added. —JST, GMA News