PhilHealth has over ₱86B unpaid claims to hospitals

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(FILE PHOTO)

Metro Manila (CNN Philippines, August 17) — The Philippine Health Insurance Corporation still has more than ₱86 billion of unpaid claims to hospitals from January 2020 until June 30, 2021.

During the House Committee on Health hearing on Tuesday, Dr. Jaime Almora of the Philippine Hospital Association (PHA) showed the breakdown of the amount:

- ₱25.6B are still being processed;

- ₱46.6B were returned to hospitals due to documentary issues; and

- ₱13.8B worth of claims were denied.

PhilHealth has already paid hospitals ₱165.9B during the same period.

"Arbitrary denial of payment resulting to losses to hospitals is not only unlawful but also morally wrong. Constant and escalating loss to hospitals will ultimately lead to collapse and failure of health care delivery system. And ultimately to the detriment of the whole country," Almora said during the hearing.

PhilHealth President and Chief Executive Officer Dante Gierran said they are now working on ways to expedite the payment of claims like the streamlining and fast tracking of claims processing, boosting the agency's information technology capacity, additional manpower, inter-regional virtual assistance in claims processing, and constant reconciliation meetings with health care institutions.

COVID-19 claims

Lawmakers also questioned PhilHealth's retroactive implementation of a memorandum circular that separates benefit packages for probable and actual COVID-19 claims.

Based on the state health insurer's Memorandum Circular 2021-008 dated June 17, 2021, patients initially treated for COVID-19 but gained negative RT-PCR test results and with ₱18,000 to ₱38,000 in hospital bills will be shouldered by PhilHealth depending on the severity of the case.

But for confirmed COVID-19 patients through swab testing, PhilHealth will shoulder ₱43,000 for mild cases and up to ₱786,000 for critical cases. These amounts were paid prior to the said circular for both probable and actual COVID-19 cases.

Lawmakers said creating separate packages for probable and actual COVID-19 cases seems to make sense, but what they don't understand is its retroactive application beginning November 2020.

"Bakit hindi siya prospective from June 2021 kung saan doon nila sinabi at ipinaalam sa hospitals at mga miyembro na ito na ngayon ang coverage ng ating COVID-19?" asked House Health Committee Chairperson Helen Tan.

[Translation: Why was it not effective prospectively, beginning June 2021 when hospitals and members were informed that this is now the new COVID-19 coverage?]

PhilHealth explained that it was in November 2020 when the board approved the policy on separate packages. But it took management seven months to implement it due to what it describes as unavoidable circumstances.

"We will not provide excuses, Madame Chair. It's just that there were several circumstances Madame Chair that went beyond our control. It's already late when the circular was published. And for this Madame Chair, I take responsibility," said Atty. Eli Santos, the acting PhilHealth Chief Operating Officer.

But lawmakers insisted hospitals and patients should not suffer due to management problems within the agency and suggested to scrap the retroactive implementation of the circular right away.

PhilHealth has no readily available data on the possible financial impacts of the possible removal of the retroactive implementation provision of the memorandum circular to its funds.

"Hindi naman pwedeng nagkamali ang ating management, may kahinaan sa pag-implement, ganon-ganon na lang. Gusto naming malaman, ano ang impact niyan sa pondo. Kasi as we all know, lahat tayo nagko-contribute sa PhilHealth. Pera ‘yan ng taumbayan," Marikina City Representative Stella Quimbo said.

[Translation: We cannot just let the management's shortcomings in implementation slide. We want to know its impact on the fund. Because as we all know, we all contribute to PhilHealth. It's a public fund.]

Gierran said he would tackle the matter with the board, chaired by Health Secretary Francisco Duque, in their Aug. 25 meeting.

"I would certainly recommend to the board, being the highest authority in the corporation, to have this matter be taken for consideration and favorable action," said Gierran.

Bayan Muna Representative Carlos Zarate meanwhile called for accountability on the side of PhilHealth's management on the issue.

"Ang mali ng agency, hindi dapat ang magsa-suffer ang publiko," Zarate said.

[Translation: The public should not suffer from the mistakes of the agency.]