A Bohol-based hospital has been fined and had its accreditation revoked for submitting false claims to the national health insurance program, officials said Friday.
The Philippine Health Insurance Corporation (PhilHealth) ruled that Calape Mother and Child Hospital in Bohol province committed “misrepresentation by furnishing false or incorrect information” in violation of regulations.
According to the decision, copy of which was recently obtained by The Bohol Tribune, the hospital filed a claim for a patient diagnosed with moderate-risk community-acquired pneumonia.
However, an investigation found the diagnosis was inconsistent with the patient’s medical records.
Dr. Ceferino B. Bañaga, a medical specialist who evaluated the case, concluded the patient did not actually suffer from pneumonia as claimed.
The decision bared that the hospital “either upcased the final diagnosis or indicate an unrelated illness of higher severity” to receive a larger insurance payout.
PhilHealth said the hospital failed to respond to the formal charges despite being given 15 days to file an answer.
As a result, judgment was rendered based on available evidence.
The agency fined Calape Mother and Child Hospital P100,000 pesos and revoked its accreditation. It was the hospital’s fifth offense of this nature, according to the ruling.
Additionally, the hospital was ordered to return any amount “unnecessarily paid” by PhilHealth for the claim in question.
“Thus, taking into account the foregoing facts and the uncontroverted documentary evidence adduced by the Complainant, it is clearly established that Respondent deliberately falsified the final diagnosis of the patient by making it appear that the latter suffered a compensable illness with higher severity in order to gain higher benefit payment,” PhilHealth decision document states.
PhilHealth, which administers the country’s universal health coverage program, has stepped up measures to detect and penalize false claims in recent years.
Under Philippine law, healthcare providers found guilty of fraud or misrepresentation can face fines, revocation of accreditation and criminal charges.
The agency has pledged stricter enforcement to protect the integrity of the insurance system.
PhilHealth said the case shows its commitment to safeguarding public funds and ensuring beneficiaries receive appropriate care.
The agency has encouraged healthcare providers to adhere strictly to clinical guidelines and documentation requirements when submitting insurance claims.