Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre Building, 709 Shaw Boulevard, Pasig City
ARBITRATION OFFICE

PHILIPPINE HEALTH INSURANCE CORPORATION

Complainant,

- versus - PHIC Case No.HCP-XI-16-

1833

For: Misrepresentation by
Furnishing False or Incorrect
Information and Breach of the
Warranties of Accreditation
COMPOSTELA VALLEY PROVINCIAL
HOSPITAL-MARAGUSAN,
Respondent.
x-------------------------------------------x

ANSWER

Respondent, COMPOSTELA VALLEY PROVINCIAL

HOSPITAL-MARAGUSAN (CVPH-Maragusan), through the
Provincial Economic Enterprise Management Office (PEEMO)
represented by Dr. Ferdinand Anthony C. Soberano, Depertment
Head, assisted by the undersigned Provincial Legal Officer and to
the Honorable Arbitration Office most respectfully states, that:

CVPH-Maragusan is under the supervision of the Provincial

Economic Enterprise Management Office (PEEMO) of the
Provincial government of Compostela Valley by virtue of
Provincial Ordinance No. 07-2010, with Dr. Ferdinand Anthony C.
Soberano as Department; It is respectfully manifested that
Rerspondent CVP-Maragusan through the PEEMO Department
Head desires to be present before the Honorable Office personally
with the assistance of counsel in case hearing/s shall be deemed
necessary;
The respondent further states, THAT:

1. The allegation in paragraphs 1 and 2 of the Complaint are

admitted;
2. The allegation in paragraph 3 of the Complaint is
admitted with respect only to the fact that CVPH-
Maragusan filed the said PhilHealth claims involving the
confinements of the mentioned patient and likewise
admitting the existence of the Medical Records and other
pertinent documents relative to the confinement of
patient Juanito M. Tan but subject to affirmative
defenses;

3. The allegation in paragraph 4 of the Complaint is

admitted with respect only to the fact that Atty. Maria
Primarisa C. Guipo of the Legal Office of PRO XI
conducted a validation of the above-mentioned claims,
subject to the affirmative defenses;

4. The allegation in paragraph 5 of the Complaint is

admitted insofar as the fact that Atty. Guipo interviewed
three (3) employees of CVPH, namely Jo-er R. Eruela,
Analyn M. Cuamag and Eulogio L. Verano Jr. as well as
admitting the existence of the explanation and letters of
explanation of the said employees, subject to affirmative
defenses;

5. The allegation in paragraph 6 of the Complaint is

admitted insofar as it is the same tenor as that stated in
 the affidavit of explanation and explanation letters of the
three employees, subject to affirmative defenses;

6. The allegation in paragraph 7 of the Complaint is hereby

admitted insofar as the fact that the dates in the original
clinical charts were not altered subject to affirmative
defenses;

7. The allegation in paragraph 8 of the Complaint is hereby

denied, the truth being that as stated in the affirmative
defenses;

8. The allegation in paragraph 9 of the Complaint is hereby

denied, the truth being that as stated in the affirmative
defenses;

AFFIRMATIVE DEFENSES

9. Respondent Compostela Valley provincial Hospital-

Maragusan (CVPH-Maragusan) is a government hospital
operated and supervised by the Provincial Government of
Compostela Valley under the Provincial Economic
Ecterprise Management Office (PEEMO) headed by Dr.
Ferdinand Anthony C. Soberano. The Provincial Economic
Enterprise Management Office was created to handle
hospital operation and is mandated to comply and assure
that the very system of proper filing of PHIC claims;

It is noteworthy that the facts and circumstances of this

case arose from the same facts and events which was the
 subject of the Field Report of Atty. Maria Primarasa C.
Guipo of the Legal Office of PRO XI_________, although
involving different Philhealth claims;

THEN COMPLAINT FAILED

TO STATE A CAUSE OF
ACTION AGAINST CVPH-
MARAGUSAN

10. Three (3) employees of CVPH-Maragusan namely, Jo-er

R. Eruela, Analyn M. Cuamag and Eulogio L. Verano, Jr.
assumed full responsibility of the alleged tampering of
PhilHealth claims;

11. Jo-er Eruela, a regular employee of CVPH-Maragusan

categorically stated in her Affidavit of Explanation:

xxx xxx xxx

d. That because of transfer of chart

records and the additional bulk of
workload due to return of documents
mentioned above, we encountered
difficulty in completing the PhilHealth
documents for timely submission
realizing that some claims would
become stale as they were already
beyond the 60-day reglementary period
of filing claims;
e. That I and my other colleagues,
out of concern, decided that we will
adjust the dates of those claims
which already nearly lapsed because
we wanted to avoid the blame of our
superiors/ employers if those claims
would be wasted; [emphasis supplied]

f. That although aware that

changing the dates were irregular,
we did it with good intention and in
good faith, so that those claims
which was validly filed on time by
PhilHealth members would not
lapse bearing in mind that its proceeds
will inure to the benefits of our thriving
hospital and can ultimately support
other patients who are in dire need of
our medical services; [emphasis
supplied]

g. That we did it out of our concern for

our employer and not for personal
interest because nothing will redound
to our own pocket if the claims would
be approved and released but all will go
to the trust fund of the hospital;

xxx xxx xxx

12. Jo-er Eruela apparently referred to colleagues
Analyn Cuamag and Eulogio L. Verano Jr.;

13. Analyn Cuamag, in her Explanation Letter likewise

categorically stated in the Cebuano dialect, that:

xxx xxx xxx

“Mao nga nag advice advice ang

among Section Head nga si Jo-er R.
Eruela nga usabon na lang ang
petsa sa pipila ka claims. Maoy
hinungdan nga nausab o na tampered,
ka yang advice sa among head e try
lang ug padala kung makalusot ba, kay
saying nga dili mabayaran ang mga
meds, supplies ug uban nga mga
charges nga nagamit sa sulod sa
hospital, kay iyang pagtuo sa among
head nga kung dili kin I mabantayan sa
PHIC igo ra kini nila e return ug e deny,
Ug kini ng aplano wala nakabalo
ang among Chief of Hospital ,
administrative officer ug ang among
head nurse.” [emphasis supplied]

xxx xxx xxx

(TRANSLATION: Our Section Head Jo-

er Eruela advised us to change the
dates of some of the claims. That’s
 the reason why the dates were
changed or tampered, because the
advice of our head (Jo-er R. Eruela) is
just to try if it might work, because it
would be a waste if Meds, supplies and
other charges used in the hospital will
not be paid. Because it is the belief of
our head that if PHIC will notice they
will just return and deny the claims.
This plan is without the knowledge
of our Chief of Hospital,
administrative officer and head
nurse.”

14. Eulogio L. Verano Jr. in his letter of explanation likewise

categorically stated:

xxx xxx xxx

“mao nga nag advice ang among section

head nga si JO-ER ERULA nga usabon
na lang petsa sa pipila ka claims. Maoy
hinungdan nga nausab ang petsa o na
tampered ang maong dokumento, kay
base sa among head e try lang namo
ipasa kay saying nga dili mabayaran
mga Meds Supplies ug uban nga
charges nga gigamit sa sulod sa hospital
total ang maong chart philhealth In
patient man gyod. Kay kon kini
mabantayan sa Philhealth igo ra kini nila
 e return ug e denied. Kini nga mga
desisyon wala masayod ang among
chief of hospital ug admin officer.”

(TRANSLATION: That’s why our Section

head Jo-er Eruela advised us to change
the dates of some of the claims. That’s
the reason why the documents were
changed or tampered, because
according to our head it would be a
waste if the meds, charges and supplies
used in the hospital would not be paid,
anyway said chart is really a Philhealth
patient. Because if PHIC will notice they
will just return deny and deny the claim.
“This decision is without the
knowledge of our Chief of Hospital
and administrative officer.”

THE FINDINGS OF
ATTY. PRIMARISA C.
GUIPO, SPECIAL
INVESTIGATOR III,
SHOWS THAT THE
CHIEF OF HOSPITAL
AND ADMINISTRATIVE
OFFICER OF CVPH-
MARAGUSAN WERE
NOT AWARE OF THE
TAMPERING.

15. The Field Report of Atty. Maria Primarisa C. Guipo,

categorically stated, that:
 “The three employees assured that
their Admin. Officer Allan U.
Lagumbay and their Chief of Hospital
Dr. Ferdinand Soberano were not
aware of the tampering as the
Philhealth Claim Forms and the
attachments which were
submitted to them for their
signature were already tampered
and they were not aware of the
same.”

16. In the same vein, Atty. Primarisa C. Guipo, Special

Investigator III, PhilHealth Regional Office XI, in her
Affidavit stated that:

“Based on the Affidavit and Letters of

Explanation submitted by the
aforementioned employees, they
admitted that the tampering of the
confinement period and the dates in
the receipts was of their own
volition and was done in the hope
that the 44 Claims would still be paid
and or refunded by the PHIC.

17. It is evident that there is no cause of action against

respondent CVPH-Maragusan. The three employees, in
their affidavit and explanation letters, and even during
the investigation conducted by Atty. Primarisa C. Guipo,
 Special Investigator III, Philhealth Regional Office XI,
admitted that they committed the tampering of PhilHealth
claims. The three employees likewise admitted that the
tampering of PhilHealth claims was without the
knowledge of the Chief of Hospital and Administrative
Officer. CVPH management had no knowledge of the
tampering nor consented to such. Further, CVPH
management did not ratify the acts of tampering made by
the three employees.

18. Any fraudulent and/or negligent actions of the

employees are personal in nature and shall be attributed
and charged to the erring employee;

19. Considering that the tampering were personal acts of

the three employees, the same should not be chargeable
or attributable to CVPH-Maragusan. It was fraudulently
done by the subject employees in their personal capacity
and not under any order from the Chief of Hospital or
Administrative Officer.

20. The main purpose of the operation of CVPH-Maragusan

is public service, that is, to provide quality health care
services to the constituents of Compostela Valley; Such
direction is in line with the mandate of PhilHealth, which
is to provide accessible and affordable health care
services to Filipinos;

21. CVPH-Maragusan is an institution located in an area

categorized by the Department of Health as
Geographically Isolated and Disadvantaged Areas (GIDA)
 and is the only hospital to serve the surrounding
communities. If the hospital’s PhilHealth accreditation will
be suspended or revoked, no other hospital will be able to
serve the constituents in the area specifically the poor
and all PHIC members; CVPH-Maragusan is highly
dependent to PHIC reimbursement that any loss of
reimbursement shall effect the hospital’s sustainability
plan;

REFORMS IN CVPH-MARAGUSAN

22. CVPH-Maragusan has already instituted reforms with

respect to its policies, guidelines and hospital personnel;

23. Special focus is given on handling of PhilHealth claims.

In view thereof, Compostela Valley Provincial Hospital in
coordination with PhilHealth Regional Office XI-Davao City
conducted an in depth PHIC Orientation Seminar for the
purpose of enhancing the knowledge and skills of the
PHIC processors, especially of CVPH-Maragusan. The
participants of said orientation seminar were the
Administrative Officers, nurses, medical specialists and
doctors of CVPH. The speakers from PHIC are Dr. Ruben
Lucena, Head, Claims Processing Unit, PHIC XI, Ms. Drolly
J. Baws, SIO-II, PHIC-Nabunturan Service Office and Ms.
Maria Lorenza J. Tapiz, Social Insurance Assistant;

24. Furthermore, a Coordination Meeting with PHIC

personnel and hospital staff-in-charge in facility based
 enrollment, Point of Care Program and Hospital PHIC
Claims processor was likewise conducted;

25. A seminar on Medical Jurisprudence for Hospital

Personnel was likewise recently conducted and
participated by CVPH-staff;

26. Moreover, follow-up programs and policies were

likewise implemented by CVPH-Maragusan such as
improving the medical records system, the hiring of new
personnel to meet scheduled deadlines, weekly
transmittal of PhilHealth records/documents to the
PhilHealth Office, conduct quality circle meeting services,
ensuring that all the charts from hospital personnel are
completed, constant communication between CVPH-
Maragusan and PHIC-Service-Nabunturan, LHO;

27. Dr. Ferdinand Anthony C. Soberano as the Department

Head of PEEMO requires the stringent review of
documents, claims and other relative documents before
forwarding such documents to the PHILHEALTH;

28. Moreover, a new Chief of Hospital for CVPH-Maragusan

was appointed, in the person of Dr. Neil Estoya. Also Alan
Lagumbay, was replaced by Visioumen Loney as the
Administrative Officer of CVPH-Maragusan. Mr. Eulogio L.
Verano’s employment with CVPH-Maragusan is aleady
severed, whereas Jo-er R. Eruela and Analy M. Cuamag
are currently facing administrative charges.
 PRAYER

WHEREFORE, in view of foregoing, it is most respectfully

prayed of the Honorable Arbitration Office that judgment be
rendered THAT:

1. The tampering of PhilHealth claims were in fact committed

by employees Jo-er R. Eruela, Analyn M. Cuamag and
Eulogio L. Verano, Jr. on their own volition without the
knowledge of the Chief of Hospital or Administrative Officer
and without the knowledge of CVPH-Maragusan; and

2. The case for Postdating of Claims, Misrepresentation by

Furnishing False or Incorrect Information and Breach of the
Warranties of Accreditation (Sections 143, 144 and 150 of
the IRR of R.A. 7875) against Compostela Valley Provincial
Hospital-Maragusan be dismissed for lack of cause of action.

Other relief, just and equitable are likewise prayed for.

RESPECTFULLY SUBMITTED.

02 June 2016, Nabunturan, Compostela Valley (for

Pasig City), Philippines.

COMPOSTELA VALLEY PROVINCIAL

HOSPITAL-Maragusan
 Represented By:

FERDINAND ANTHONY C. SOBERANO, MD.FPSMS

Department Head
Provincial Economic Enterprise Management Office
Compostela Valley Province

Assisted by:

ATTY. RICHARD B. LIBAN

Provincial Legal Officer
Province of Compostela Valley

PROVINCIAL LEGAL OFFICE

Rm. 208, 2nd Floor Provincial Capitol Bldg,
Brgy. Cabidianan, Nabunturan
Compostela Valley Province

IBP NO. 0988655 1/20/2015 Davao City

PTR NO. 5517121 1/22/2015 Compostela Valley
MCLE COMPLIANCE NO. IV-0023329
ROLL NO. 51217

Copy Furnished:

ATTY. DECTER L. NAVARRO Received by:_______

Prosecutor Date:_____________
Philippine Health Insurance Corporation
Citystate Centre, 709 Shaw Blvd.,
Pasig City
 VERIFICATION

Republic of the Philippines)

Province of Compostela Valley)
Municipality of Nabunturan)
X-------------------/

I, FERDINAND ANTHONY C. SOBERANO, of legal age,

married, Filipino, duly appointed Provincial Economic Enterprise
Management Officer of Compostela Valley, with office address at
Capitol bldg., Cabidianan, Nabunturan, Compostela Valley,
depose and say THAT:

1. I am the incumbent Provincial Economic Enterprise

Management Officer of the Provincial Government of
Compostela Valley, as such duly authorized to represent
the Province in the instant proceedings;

2. I have caused the preparation of the instant Answer with

special affirmative defense/s;

3. I have read the contents thereof and the allegations are

true and correct of my personal knowledge and based on
authentic records;

I hereby affixed my signature this _____ day of

___________ at Nabunturan, Compostela Valley.

FERDINAND ANTHONY C. SOBERANO

Affiant

SUBSCRIBED AND SWORN to before me this ______

day of ____________ at Nabunturan, Compostela Valley.
SENIOR ARBITER
Arbitration Office
Philippine Health Insurance Corporation
Pasig City

Greetings:

Respectfully submitting the instant Answer for the kind

consideration and approval of the Honorable Arbitration Office.

DR. FERDINAND ANTHONY C. SOBERANO

PEEMO – Department Head
Compostela Valley Province Hospital