PhilHealth Fraud

Develop fraud theory:

 Who might be involve?
- Executive officers of PhilHealth and private and public hospitals
- Top management of each PhilHealth Branch
- Top management of public and private hospitals
- Doctors and nurses of hospitals
- Rank and file employees of PhilHealth and hospitals
 What might have happened?
- The frauds start years ago and the executives has been covering up
those embezzle money and later on announcing to the public the
possible losses in the near future.
 Why might the allegation be true?
- Since it’s a government owned health insurance and almost citizens or
residents of the Philippines are member and also there is a government
funds for healthcare and a lot of charities that will those who can’t
afford to pay their bills in the hospitals. So it’s impossible for government
health insurance to incur losses.
 Where are the possible concealment places or methods?
- The fraud may happen at the hospitals where in the patients are billed
for services not rendered and medical treatments of ghost patients.
 When did this take place? (past, present, or future)
- This scheme started years ago.
 How is the fraud being perpetrated?
- The people who are involve are part of a syndicate.
- By charging patients for services not rendered.
- By buying fake brand of medical equipment instead of the original
and donating to any health facilities.
- Funding the medical treatment of ghost patients.
Determine where the evidence is likely to be:
 On-book vs. Off-book
-
 Direct or circumstantial
- Direct for a reason that the employees who are involve are receiving
allowances to commit fraud and because the whistle blower
complained about the delayed salaries.
 Identify potential witnesses
- Either one of the executive, top management, or rank and file
employee who have been part of the fraud scheme.
- The co-employees.
 What evidence is necessary to prove intent?
 Number of occurrence
- The former president and the 8 other officers in which they gave
P1.9billion to hospitals with fraud cases.
- In 1029, it was reported that PhilHealth loses an average of 7.5% which
is equivalent to P10 billion when in fact that amount is stolen.
- One of the executive admitted that out of the P136 billion P10 billion
goes to their pockets.
 Other areas of impropriety
- In 2015, 6 facilities conduct a cataract surgery to the PhilHealth
members without consent from the higher up.
 Witnesses
- Those who are involve in the fraud scheme.
- Those who are affected by the fraud scheme.
- Co-employees of the involve employee.
Prepare chart linking people and evidence

Executive officers

Philhealth

Bribe them with money

Funding the False claims of

the Hospitals

Top Manager/doctor
Top Manager
Hospitals
Philhealth Funding the False claims of
the Hospitals

Bribe them with Money Bribe them with money

Rank & file employees

Employees will create

ghost patients
Determine defences to allegation
- One of the involved executives defend that the ahead release of IRM
funds to the other hospital or clinic because they a submitted the
complete application form for the IRM but it was questioned that why
some hospitals are still waiting for the allotment of IRM funds. So it was
speculated that there is a favouritism between the hospitals officer and
PhilHealth officers.

Sources:
https://mb.com.ph/2020/08/10/hospitals-main-sources-of-fraud-philhealth-chief/
https://www.rappler.com/newsbreak/iq/list-corruption-controversies-philhealth-
philippines