The Philippine Health Insurance Corporation (PhilHealth) is acknowledging the complaints of hospitals in claims processing delays. On the directive of its President and CEO Atty. Dante A. Gierran, the Agency said these issues are being closely addressed by no less than the Chief Operating Officer and the Regional Vice Presidents through constant dialogues and reconciliation of figures with hospital representatives at the regional level. The allegations of huge payables of the Corporation were dispelled after these reconciliation meetings.
Based on records, PhilHealth has paid a total of Php166 B for some 13.6 million claims, or 76.4% of the almost 18 million claims received from its accredited government and private hospitals in the country from CY 2020 to June 30, 2021. The Corporation said it is working double time to process the remaining 12% amounting to Php25.6 B which are in varying levels of processing in its offices.
Some 8% of total claims received were returned to hospitals (RTH) for compliance with identified deficiencies while 3% were denied due to non-compliance and various violations of existing rules and regulations, PhilHealth said.
Of the total claims received during the same period, almost 10 million claims were from accredited private hospitals, of which, 8.2 million (82%) amounting to almost Php 96 B has been paid while over 892,000 claims amounting to Php14.4 B are still under process.
The Corporation would like to clarify that the Php 6.3 billion paid to 206 hospitals as claimed by the PHAPi in recent news reports refer to the partial payments made by PhilHealth under the Debit-Credit Payment Method (DCPM) for hospitals with COVID cases in IATF identified critical areas during the initial phase of implementation.
The seeming discrepancy in figures between PhilHealth and the hospitals may be due in large part to differences in accounting treatments, the Corporation said adding that during the claims data reconciliation meetings with a number of hospitals, it was noted that hospitals have been including denied and returned-to-hospital claims in their accounts receivables while PhilHealth recognizes only good claims as its payables pursuant to prevailing government accounting rules and regulations. This accounting practice was earlier validated during the House Committee on North Luzon Growth Quadrangle hearing with hospitals and PhilHealth in June of this year.
Pandemic response
In support of the Government’s response to the COVID-19 pandemic, PhilHealth said it has paid almost Php12 billion for benefit claims against its COVID-19 portfolio consisting of testing packages (inclusive of tests conducted by the Philippine Red Cross), community isolation benefit package and hospitalization cases. This comprises 56% of total received COVID claims from affected areas.
For in-patient claims, the agency said relevant policies have been issued to clarify claims concerns in processing, and that the payment of testing benefits, non-compliance to required documents like the DOH-required Claims Investigation Form (CIF) and eClaims submissions have caused delays in claims payment.
PhilHealth, with all its Regional Offices, said it is committed to assist hospitals in the reconciliation of claims records, and to guide them in the effective compliance of returned-to-hospital claims.
According to PhilHealth, the Agency remains steadfast in its commitment to pay hospital claims that are in order and compliant to rules and regulations.
It added that Insurance fraud is a reality in most insurance systems. “As steward of public funds, the Corporation is accountable to its members and duty bound to protect the funds from fraudulent claims. Hence, the Corporation has intensified its efforts in fraud identification, control, and prosecution,” it concluded.
