ILOILO CITY – The Philippine Health Insurance Corp. has filed administrative cases against four Negros Occidental-based doctors in relation to irregularities in insurance claims for cataract surgeries.
Named respondents were physicians Nonito Avecilla, Miguel Sarabia, Danilo Guanzon and Leopoldo Cuaycong, a copy of the PhilHealth complaint showed.
The doctors are facing a total of 29 charges for allegedly padding claims, misrepresentation and violations of provisions of the PhilHealth warranties of accreditation and the Republic Act 7875 (National Health Insurance Act) before the PhilHealth's prosecution department.
Avecilla faces the highest number of counts with 15, followed by Cuaycong (7), Sarabia (6) and Guanzon (1).
All respondents are affiliated with the Bacolod Our Lady of Mercy Specialty Hospital, except for Guanzon, who is affiliated with the Bacolod Adventist Medical Center .
The violations are grounds for the non-renewal or revocation of accreditation of doctors and hospitals and the imposition of a fine from P10,000 to P50,000. Administrative charges could also be filed before the Professional Regulatory Commission for the cancellation of the professional license of doctors found guilty.
Criminal charges for falsification of documents and estafa could also be filed against the respondents, Jay Villegas, manager of the PhilHealth's Fact-Finding and Administrative Investigation Department, said in a telephone interview.
PhilHealth last month ordered a stop to payment of claims for cataract surgery during medical missions and through recruitment schemes amid reports of irregularities in claims of hospitals and doctors involving hundreds of millions of pesos.
The violations which were first reported in 2004 involved complaints that the hospitals and doctors padded their claims to maximize payments by including medicines and services that were not availed of by the cataract patients.
PhilHealth had also investigated a controversial scheme on the recruitment of patients through "seekers" or "recruitment agents" sent out by ophthalmologists in coordination with the hospitals where the operations are performed.
PhilHealth paid 19,145 cataract-related claims reaching around P390 million to hospitals and doctors in Western Visayas from January 2004 to June 2007, according to data from PhilHealth's Corporate Planning Department.
These include P66,989,720 in 2004 (3,477 claims), P123,516,910 in 2005 (6,203 claims), P140,241,210 in 2006 (6,538 claims) and P58,885,130 from January to June this year (2,927 claims).
Doctors performing these cataract operations are also earning millions of pesos from PhilHealth.
In 2006 alone, PhilHealth paid P48,491,030 in professional fees to 10 doctors in Western Visayas for eye-related operations.
One ophthalmologist received P15,778,650 for 2,071 claims while the next highest paid got P14,226,450 for 1,825 claims. These equal a monthly average ranging from P1.1 to P1.3 million in earnings.
During the same year, the government insurance corporation paid P78,411,289 to 10 hospitals in the region for eye-related claims.
Philhealth's regional offices in Western and Central Visayas are also investigating the death of a PhilHealth member who died after undergoing cataract surgery.
The Philippine Academy of Ophthalmology said it was saddened by the filing of cases against their colleagues but welcomed the move of PhilHealth.
"It is painful but also necessary," PAO national president Dr. Ma. Dominga Padilla said in an earlier telephone interview.
Padilla said they are ready to help their members who have been charged. "But if they are found to be guilty of the charges, necessary functions should be imposed in order to protect the insurance system and the integrity of the profession."
The 1,300-member PAO had earlier called the manner of getting patients by using recruiters-agents or "seekers" as unethical.
Padilla had said that the practice violates provisions of the Academy's Code of Ethics and Implementing Rules and Guidelines.*NPB
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