VOLUME 15 (Supplement)

Measuring the extent of fraudulent-risky benefit claims in PhilHealth

In 2015, PhilHealth estimated that a total of PhP 2 billion was made in improper payments to potentially fraudulent benefit claims. This study aimed to determine the extent of fraud in payments made by PhilHealth for benefit claims and to map out areas in PhilHealth claims processing system where fraud is highly susceptible to be committed. This study utilized a mixed-method design. Fraud risk factors and fraud risk index were determined through literature review, key informant interviews, focus group discussions, and records review; these were validated through a series of round table discussions with personnel from relevant PhilHealth departments. Benefit claims applications in general start in the accredited health facility. Each health facility then submits the accomplished benefit claims application forms to the corresponding PhilHealth Regional Offices (PROs). PROs then evaluate the claims and release the reimbursements for the claims, when approved. In 2016, PHIC shifted from manual to electronic processing of benefit claims to simplify and lessen the turnaround time of the process. Specific health care facilities, health care professionals, and illness types were identified as fraud risk factors. Review of 4,413 doubtful claims from PhilHealth’s Fact-Finding Investigation and Enforcement Department from 2010 to 2018 showed that eight health care facilities were continually investigated from 2014 to 2015. Also, two medical doctors would be investigated for more than one year and more than one instance per year for doubtful claims. Top illness types of doubtful claims vary per year. Application of the identified factors associated with suspicion of fraud to 2015, 2016, 2017, and 2018 claims datasets yielded an annual fraud index from 0 to 127.70 points. Based on fraud risk points and fraud risk categories, the estimated peso value for all years of none to low-risk claims was higher than 85% of the total reimbursed value. On the other hand, the estimated peso value of claims with moderate to high risk was 14.42% in 2015 and dropped to less than 4% for 2016 and 2017, and then climbed up to 7.9% in 2018. System support for fraud detection may enhance the effectiveness of fraud prevention. The new subsystems may include an automated Relative Size Factor (RSF) test, Same-Same-Same (SSS) test, Same-Same-Different (SSD) test, identification of admissions beyond maximum bed capacity, and training and use of checklist on the fraud-related component of Clinical Pathways.