Santo Domingo.-A “call center” parallel to authorize proceedings never carried out, express payments to suppliers, a contract canceled by public hiring and a financial lifeguard of the National Social Security Council (CNSS) and fraud in the authorizations of medicines by at least a pharmaceutical company are the lines of investigation that exposed the anti -fraud unit of the Government and which was delivered last Saturday to the Attorney General of the Republic, which with this case premieres its legal independence of the Executive Power.
President Luis Abinader, through his spokesman Félix Reina, informed that after the end of the investigation by the government instances, the case was given to the Public Ministry due to the seriousness of what was detected and that he had been investigating for months.
The state national health insurance (Senasa) is the largest health risk administrator in the country, with more than seven million members and millions of authorizations a year, which apparently gave rise to a framework to drain their funds with diverse frauds that were executed simultaneously and drained their resources, plunging it into a financial crisis that was the one that finally gave the alarm.
One of the fraud consisted of the existence of a parallel call center to give authorizations of medical procedures to patients who did not need them or require them, but that the service provider charged in complicity with internal personnel of Senasa.
He is attributed to having armed that framework to a former employee of Senasa who designed a mechanism to manufacture medical indications that later became authorizations for supposedly carried out procedures, but that did not really happen.
Although the initial research deciphered the scheme and detected some names of doctors and companies providing health services (PSS), now the Attorney General’s Office will delve to see the real and external reach involved.
The system consisted of capturing the data of the affiliates, then the indications of minor consultations, procedures or surgeries were issued without clinical support, which were then authorized expressly by the Call Center parallel and then the service provider or complicit company was paid.
The other scheme that, although ran simultaneously, was different but also drained Senasa’s finances and consisted that at least an important pharmacy chain made false reports of medicines sales using the data of affiliates that they didn’t even know.
That pharmacy did was that he subtracted up to three pesos to affiliates who had not exhausted his fee of 12 thousand pesos annually for medications assigning the family health insurance.
The company in question identified affiliates whose date to consume the 12 thousand pesos was about to expire and was accumulated. The amounts were up to three thousand pesos to prevent the affiliate from realizing.
That was taking advantage of the willingness that each affiliate has the right to consume up to 12 thousand pesos in medicines a year that is prescribed by doctors, but with the modality that they are not cumulative and if it does not consume them in a calendar year, then it returns to zero and restarts the following year only with the 12 thousand pesos.
Affiliate complaint
A case of the day, an affiliate called to claim a pharmacy when detecting a consumption of RD $ 1,817.00 that did not make. When the affiliate called to complain and threaten to take his case to the authorities, the employee of the pharmaceutical company was sincere and proposed to reimburse him the fictional consumption, add five thousand pesos in cash and facilitate the medications that are prescribed for life.
Contracts under the magnifying glass
In parallel, the General Directorate of Public Contracts (DGCP) annulled by resolution the direct contracting between Senasa and Pharmacard, in determining that it violated Law 340-06 (it did not qualify as “health service” excluded from the law, but an administrative/technological service that should be tendered).
The DGCP arranged, to protect the continuity of the service, that the contract remains in force for 70 business days while Senasa summons a competitive process.
The research application was promoted by the company DHN (Digital Health Network), who previously had the software contract that was given to Farmcard.
In this case it is the administrative annulment of a hiring that has no criminal implications and is only subject to administrative sanctions because they are procedure errors.
Although this case is not a fraud, it may have had indirect linking in the detection of fraud, since it was with the change of software managing companies when disproportion began to be detected in the billing of the same network of pharmacies.
Before the Attorney General’s Office
“Report problems.”
On Saturday, by presidential disposition, Miguel Ceara, Superintendent of Health and Occupational Risks, and Edward Guzmán, director of Senasa, deposited before the Attorney General’s Office a report with “serious irregularities.”
Law 340-06 does not regulate Senasa’s purchases
Clarification. The DGCP reported yesterday that the hiring between the health services providers (PSS) and the Senasa are not regulated by Law 340-06 of Public Contracts, but by Law 87-01 of Social Security.
But in cases of hiring of goods or services with companies without qualification as PSS issued by the SISALRIL, they are subject to Law 340-06 and enter within the framework of regulation of the DGCP.
This was reflected with the resolution of August 15 of this year where the hiring of the Farmacard company, SRL by Senasa, was left without effect, since it did not have accreditation as PSS.
