DOJ to probe reports of PhilHealth ‘upcasing’

Secretary Menardo Guevarra said the Department of Justice and the National Bureau of Investigation are willing to help the state-run Philippine Health Insurance Corporation in investigating fresh reports of alleged “upcasing.” 

Guevarra made the statement after the PhilHealth said it is conducted a probe on video posts claiming the resurgence of the so-called upcasing scheme where healthcare providers allegedly collude with patients to declare minor respiratory symptoms such as asthma as COVID-19 to claim higher benefits. 

“The DOJ-led Task Force Philhealth conducted a thorough investigation of upcasing schemes last year and cases were filed thereafter. PhilHealth is currently looking into new incidents of upcasing in relation to COVID claims,” Guevarra said. 

“With a former NBI chief as president/CEO (Chief Executive Officer), PhilHealth can very well handle this new investigation, but the DOJ and NBI will be ready to provide assistance if requested,” he added. 

Last year, the Task Force PhilHealth recommended the filing of criminal and administrative charges against seven officials of the agency for violations of the Anti-Graft and Corrupt Practices Act over their alleged involvement in a multi-billion peso fund embezzlement. 

As a form of health-insurance fraud, upcasing refers to claiming for a related illness or procedure of higher severity or complexity to gain higher benefit payment. 

Those who would be found guilty may be fined P200,000 for each count, or suspension of contract up to three years of the healthcare provider, or both.  

It also constitutes a criminal violation punishable by imprisonment of six months and one day up to six years upon the discretion of the court in accordance to Section 38 of the Universal Health Care Law.

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