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O.
1

AUDIT OBSERVATION

There is a systematic recruitment of patients at

Rizal Doctors Eye Center through different
means of solicitation of patients such as tie ups
with Local Government Units
(LGUs) and
senior citizens groups, for the purpose of
performing eye surgeries only on PhilHealth
members and claiming Philhealth
reimbursements, committing a breach of their
Perfomance Commitment as Health Care
Institution, and the Code of Ethics of Philippine
Medical Association.
a. Eleven (11) out of nineteen (19) sample
patients of Rizal Doctors Eye Center were
recruited by Seekers who performed tie-ups
with LGUs and Senior Citizens groups.
b.

Rizal Doctors Eye Center has written guidelines

on credentialing and privileging of affiliated
health care professionals included in their
Manual Operating Procedures (MOP), however,
said MOP does not contain the signature of the
approving authority. Therefore, the MOP
presented was not approved and unofficial in

FACILITYS COMMENTS/ ACTION PLAN

TIMELINE

The Rizal Doctors Eye Center (the RDEC) is

not aware of any solicitation of patients that are
treated in its facility. The RDEC has not entered
into any tie-ups, direct or indirect, with any
groups to solicit patients.

The practice of
strictly
adhering to the
policy against
solicitation will
becontinued to
The patientstreated in the RDEC facility are be
practiced
usually with admitting orders and are brought in by RDEC from
by visiting doctors/ consultants.
this day and all
the days of the
Attached is the Sworn Statement of the Medical year.
Director of RDEC stating that it is not practicing
solicitation as Annex A and made an integral
part hereof.

The RDEC has an existing signed copy of its

Manual Operating Procedures (MOP) in
compliance with the provisions of the
aforestatedPhilhealth Circular No. 10. S. 2014. It
was unfortunate that at the time of the visit, the
signed copy of the MOP was with the
Department
of
Health
(DOH)
for

The signed
copy of the
MOP or any of
its revisions
will be kept in
the RDEC
facilities as

nature, violating Philhealth Circular No. 10, s.

2014

_____________ .

compliance to
the circular
starting this
September 24,
2015.

Attached is the machine copy of the receiving

copy by the DOH indicating actual receipt by the
DOH
of
RDECs
signed
MOP
last
_______________ as Annex B

Sample patients of Rizal Doctors Eye Center

were given health care services that are
deviations from the currently accepted
standards of practice or treatment protocols
violating the Performance commitment as a
Health Care Provider, and the Clinical Practice
Guidelines for the Management of Cataract
Among Adults.
a. Fifteen (15) out of nineteen (19) sample
patients who underwent cataract surgery at
the Rizal Doctors Eye Center were not
advised or scheduled to come back for
follow- up check- up within 24- 48 hours after
the surgery, violating their performance
Commitment as a Health Care Provider and
the Clinical Practice Guidelines For the
Management of Cataract Among Adults.

The visiting doctors and consultants of RDEC

have consistently managed their patients with
utmost care and in the highest level of
professionalism. This can be shown by the
absence of any complaints against any of
RDECs consultants for malpractice and any
violations. Some patients treated in the RDEC
facilities may not have been scheduled to return

RDEC
will
instruct all its
consultants
and
visiting
physicians to
strictly observe
the
24-48
hours follow-

for check-up or follow-up after 24-48 hours but it

does not thereby mean that these patients have
been neglected in any way. The patients
attending physicians may have seen fit that the
24-48 hours follow-up is not necessary under
the circumstances and based on the status of
the treatment.
We invite the kind attention of this special audit
team that the Guidelines On The Diagnosis and
Management of Uncomplicated Cataract In
Adults was released only last August 2015 while
the audit was conducted last July 2015 which
may explain the passive observance by the
attending physicians of the said rules on checkup.

up
of
all
cataract
operation
patients.
Likewise,
RDEC
will
require
sufficient proof
from the said
physicians of
their
compliance
thereto starting
this September
24, 2015.

RDEC assures Philhealth that it will henceforth

institute the strict policy whereby all patients
operated on will be required to be seen and
followed up 24 to 48 hours after their surgery by
the attending physician or their affiliates at the
surgical center pursuant to the said circular.

b. Thirteen (13) sample patients with comorbidity conditions such as diabetes and
hypertension underwent cataract surgery
even if there were no pre-operative work- up

The RDEC respectfully clarifies that the RDEC

will
attending physicians who undertook cataract require
a
surgery have conducted the required pre- clearer form of

or medical clearance contraindicating their

performance Commitment as a Health Care
Institution (HCI).

operative work-up on all their patients.

Attached are the sample _______ form whereby
the vital signs, assessments and other results of
several tests conducted on the patient are
indicated as Annexes C, D and E and made
integral parts hereof.

pre-operative
work-up to be
filled up for all
all the patients
of its visiting
physicians
starting
this
September 24,
2015.

Further, the resident nurse of RDEC, Ms.

__________, RN, has executed an affidavit
attesting to the fact that all patients are properly
screened, assessed, evaluated and worked-up
on by their attending physicians prior to the
performance of cataract operation on them As
Annex F and made an integral part hereof.
As a moving forward action by RDEC, it will
further ensure the strict observance of the
policy wherein pre-operative workup or medical
clearance, whenever applicable, will be required
prior to a planned surgery.
c.
d. One patient who underwent cataract surgery
noted that she was not given a written advice
on the dos and donts of eye care and

It will be worthy to note that RDECs attending RDEC

physicians have been consistently issuing the continue
Habilin (post-operative instructions) and have ensure

will
to
that

schedule of medications.
Likewise, some of the facilitys written
instructions on post-operative care of the eye
which were given to some patients lack
important details, violating the Performance
Commitment as a Health Care Institutions,
Clinical Practice Guidelines For the
Management of Cataract Among Adults, and
the PMA Code of Ethics of the Medical
Profession.

required the patients or their wards to sign the

same form indicating their receipt thereof.
Attached is a sample o the said form showing
the name of the patient, procedure done, and
the instructions as Annex G and made an
integral part hereof.
Moreover, the instructions given to the patients
and/or their relatives by RDECs attending
physicians include all relevant and pertinent
instructions and information. Schedule of
medication may have been written on the
prescription or attached to the prescription thats
why some of the said instructions are not in the
Habilin itself.
To bolster the fact of the compliance by the
RDECs consultants on the matter of postoperative care, an affidavit was executed by Ms.
Rio Angeline Pealosa as Annex H hereof and
made an integral part hereof.

e. Review of clinical records of patients who

underwent ophthalmologic services at Rizal
Doctors Eye Center showed that the consent
forms of the surgical procedures do not
contain the date of patients signature, raising

The RDEC consent forms for surgical

procedures contain the date of its execution,
including the signing by the patient, at the upper
right hand corner thereof. The patients

printed
postoperative care
instructions will
be given to
every
postoperative
patient that will
conform to the
performance
commitment
as a Health
Care
institution,
Clinical
practice
guidelines for
the
management
of
cataract
among adults
and the Code
of Ethics of the
Medical
profession.
RDEC
will
ensure that the
consent forms
of the surgical

doubt on the validity of the informed consent,

violating the Performance Commitment as a
Health Care Provider and the PMA Code of
Ethics of the Medical Profession.

f. All nineteen (19) sample patients of Rizal

Doctors Eye Center were not informed of
the type of intra-ocular lens (IOL) implanted
on the affected eye and the patients were
not given IOL identification cards or stickers
as evidence of the IOL used which violated
their Performance Commitment as a Health

signature on the opposite page may not have procedures will

been written with the date but the controlling contain
the
date is the one indicated on the other side.
date
immediately
The exact and accurate date of the execution of right
beside
the consent from may be made by cross- the signature
referencing the following data date of consent of the patient
form, logbook of the operating room and the aside from the
date of the picture of the patient after the date on the
operation.
upper
right
hand corner of
Attached is the sworn statement of Ms. the first page
Pealosa stating the identical dates of several of the form.
consent form, logbook entries and pictures as
Annex I and made an integral part hereof.

The patients of the visiting

physicians of RDEC have been
informed fully on the type of IOL
to be implanted on the affected
eye. Likewise, IOL identification
cards or stickers were all given

RDEC will continuously

ensure that all patients will
be fully- informed of the
type of intra- ocular lens to
be implanted and that the
intra-ocular ID cards or

Care Provider and the Clinical Practice

Guidelines for the Management of Cataract
Among Adults.

g. Eighteen (18) out of nineteen(19) sample

patients of Rizal Doctors Eye Center who
underwent cataract surgery do not have
clinical records of the results of their
physical examinations such as visual
acuity, pinhole, slit lamp examination,
dilated Funduscopy and tonometry, at the
health care facility, casting doubt if such
examinations were conducted,
contraindicating their Performance as
Health Care Provider, Clincal Practice
Guidelines for the Management of Cataract
Among Adults, and DOH Administrative
Order No. 183, s. 2004P: Rules and
Regulations Governing the licensure and
regulation of Ambulatory Surgical Clinics.
The audit team was able to document some
lapses in the quality of care given by Rizal
Doctors Eye Center violating the performance
as Health Care Institution and the Clinical

to the patients.

stickers will be turned over

to the patients after the
Attached are three (3) affidavits surgery.
of patients attesting that they
were fully informed of the IOL
and weregiven the stickers as
Annexes J, K and L and
made integral parts hereof.

It is imperative to note that

patients of RDEC have their
own attending physicians who
are visiting doctors of the
RDECs facilities. The said
physicians usually bring the
charts of their patients to their
respective clinics where their
patients are advised to proceed
for their post-operative check
ups. These cases may explain
why the clinical records are not
in the RDECs facilities at the
time the audit was conducted.

RDEC will institute a policy

that will necessitate followups of post- operative
patients within 24- 48
hours after the surgery
and that a corresponding
medical examination chart
including visual acuity,
pinhole,
slit
lamp
examination,
dilated
Funduscopy
and
tonometry be recorded by
the attending physician
and affiliates.

Practice Guidelines for the Management of the

Cataract Among Adults.
a. Thirteen (13) sample patients Rizal Doctors
Eye Center were scheduled for yag laser
capsulotomy unnecessarily, within the span
of 1 to 3 months after the cataract surgery,
allegedly to clean the affected eye. As a
result, the procedure did not improve the
quality of vision of the patients.

RDEC conducted talks with their

visiting doctors with the end in
view of knowing what are the
instances when a yag laser
capsulotomy(YLC)
may
be
scheduled months after a
cataract surgery.
YLC was explained to be
necessary in instances where
the lens used unusually is
tainted in a shorter period of
time. This can happen when
several conditions happen to a
patient
like,
_______
,
__________ , or __________ .
With the professionalism of the
visting doctors of RDEC, it will
be highly improbable for them to
conduct YLC if the same is not
called for or is not necessary
and
desirable
under
the
circumstances.
Attached is the sworn statement

Immediately,
all
YLC
procedures to be done to
cataract patients will be
with
sufficient
and
comprehensive
medical
analyses and justifications
as to why such procedure
has to be done on the
patient.
This
medical
history shall form part of
the patients chart which
will be made available to
all concerned individuals.

of DR. ________ , who

conducted YLC to a patient after
____ months from the cataract
operation
due
to
urgent
necessity as Annexes M and
N and made integrals part
hereof.
b. One patient of Dr. Francis Albert Guerrero
who underwent cataract surgery on the
right eye at Rizal Doctors Eye Center
resulted to blurring of vision allegedly
because the lens ay hindinakabukas at
hindinakasentro. Three months after the
cataract surgery, patient was subjected to
yag laser capsuloomy on the affected eye,
however, no improvement of vision was
achieved.

With all due respect, RDEC

believes that the prognosis and
subsequent procedures that the
concerned patient underwent
was subject to the sole medical
management and professional
decisions of Dr. Francis Albert
Guerrero, a visiting consultant.
There
were
certain
developments that necessitated
further medical management
that was subject of the attending
physicians
professional
discretion.
Attached is the sworn statement
of Dr. Guerrero explaining the
status of the patient as Annex
O and made an integral part
hereof.

All patients charts and

other medical records will
be made available to
concerned individuals who
may have the authority to
verify the status and other
details of the procedures
and other processes such
patient underwent in order
that there may be an
increased
level
of
transparency
without
necessarily violating the
confidentiality between the
patient and the doctor.

There is possible fraud in the filed claim of

Rizal Doctors Eye Center when one patient
claim that he does not know the name of the
surgeon indicated in the Phihealth records
who allegedly performed the fluorescein
Angiography and claimed the Philhealth
reimbursement. Thereby, committing
misrepresentation by furnishing false or
incorrect information on the claim forms,
violating Title IX, Rule I, Section 154, of the IRR
of R.A. 10606 ( Offenses of Heath Care
Institutions).

RDEC would like to respectfully

state that the name and
signature of the doctor in the
Philhelaths records mentioned
by the patient in the observation
would have most likely been that
of the Medical Director, Dr.
Candice Vergara ______ . For
the
record,
patients
who
undergoesFlouresceinAniograph
y (FA) have already been issued
their respective admitting order
by their attending physicians.
That doctor may be the doctor
the patients have in mind who
handled their FA.
The FA is conducted by highlytrained technicians while the
form is signed by the Medical
Director and not the physician
who issued the admitting order.

There could be no room for

fraud that could have attended

all the FA procedures in RDEC
since all are verifiable from the
different records which could be
cross-referenced like the (1)
admitting order indicating names
and
other
personal
circumstance of the patients; (2)
logbook
of
the
operating
room/laboratory room; and (3)
the pictures of each patient
taken after the procedure is
done.

Rizal Doctors Eye Center, Inc. - Cainta , Rizal is

Top 10 among the Ambulatory surgical Clinics
( ASCs) in NCR with highest claim
reimbursements for 2014.

RDEC implements the No

Balance Billing (NBB) scheme
program of Philhealth. Patients
in the rural areas of Caintay,
Taytay, AngonoBinangonan and
other neighboring Rizal towns
may have opted to avail of the
facilities of RDEC considering
also the NBB scheme. Between
an ACS where patients still has
to shed out additional amount,

patients will most likely opt for

an ASC like RDEC who
implements a NBB policy.
It is important to emphasize
here that actual services were
rendered and such services
could all be accounted for.
RDEC may be one of the top
ASCs in NCR but the financial
records show that the 2014
income is lower than the
generated income last 2013.
Attached is the sworn statement
of Ms. Heidi _____ explaining
the financial records of RDEC
as Annex P and made an
integral part hereof.

Eighteen (18) out of nineteen (19) respondentpatients of Rizal Doctors Eye Center claimed
that they reached the facility through the
coordinator or form of recruitment which
contradicts to the faciltys declaration based
on submitted Catarac Pre- Surgery
Authorization (CPSA) as walk-in, whichis a
breach to their Commitment.

RDEC respectfully reiterates

that it is not aware of any person
or entity who could have
claimed to be acting for and on
its behalf.

RDEC will continue to

strictly observe the policy
of no solicitation or
utilization
of
any
coordinator
to
seek
cataract patients.

There is a frequency of multiple procedures on

the same eye filed by Rizal Doctors Eye Center
which may reflect poor quality care and must
first be ascertained as to their necessity of
performing it.

We respectfully opine that

multiple procedures on the
same eye is tantamount to poor
quality of care of the attending
physicians of the RDEC.
The management of the patients
is within the sole responsibility
of their attending physicians. It
is reasonable to believe that the
king of procedures and other
medical
management
implemented by the attending
physician is what is necessary
and
desirable
under
the
circumstances surrounding a
patient.
Attached are the verified
statements of Dr. ______ and
Dr. _______ elucidating why
multiple procedures on the
same eye to their patients as
Annexes Q and R and made
integral parts hereof.

Rizal Doctors Eye Center was able to

implement No Balance Billing (NBB) to
fourteen (14) of the sample patients consistent
with the aspirations of Universal Health Care.
However, (5) sample patients incur out of
pockets expenses during the surgery.

The reason for possible out of

pocket expense of patients who
have previously availed of NBB
program is the additional
services or utilization of a more
expensive medical implement
that are completely outside the
NBB program.
If patients opt to avail of such
additional expenses that would
necessarily entail additional cost
for them, RDEC will follow such
request.
But it is important to note that no
additional
out
of
pocket
expenses were erroneously
billed against Philhealth which
could undermine the program.
Also, it is apparent that the
additional expenses spent by
the patient are not being
complained of.

Even when requested by

the patient, no additional
procedure
or
medical
implement will be provided
by RDEC if this will entail
an out of pocket expense
for an NBB patient.