Philhealth vows to pay claims of HCFS meeting requirements

THE Philippine Health Insurance Corp. (Philhealth) announced plans to initially pay 60 percent of the total applicable inprocess claims of each eligible health care facility (HCF) located within the National Capital Region (NCR) Plus bubble, Pampanga and Batangas.

Following President Duterte’s order to fast track payment to hospitals, Philhealth released circular 2021-0004 detailing the guidelines on its adoption of a debit-credit payment method (DCPM) to settle accounts payable to these select health centers.

The move comes only after the Private Hospital Association of the Philippines Inc. (Phapi) issued a statement lamenting that payment delays from Philhealth have culled the capacity of its member-private hospitals to accommodate more patients suffering from the coronavirus disease of 2019.

Philhealth President and CEO Dante A. Gierran said in a circular dated April 8, the DCPM shall be applicable only to in-process claims received from March 8, 2020 to April 7, 2021. These claims exclude “Return-to-hospital” and claims that were denied and referred for further investigation.

The payment also excludes claims approved for payment as of April 7, 2021. However, Philhealth said it can adjust the cut-off dates for claims included in the DCPM, subject to the approval of its Board.

In-process claims refer to those claims received for processing without final decision on whether it is denied, “return-to-hospital” or paid.

To be eligible for the DCPM, Philhealth said HCFS should be within NCR, Batangas, Bulacan, Cavite, Laguna, Pampanga and Rizal. Apart from these, HCFS must have claims for Philhealth Covid-19 packages, have no “interim reimbursement mechanism fund” balance on record and their accreditation must not be suspended during the applicable period. Under the DCPM, Philhealth said it will pay the remaining 40 percent of the total amount of “good claims” after HCF’S full compliance to existing claims processing requirements and procedures and full reconciliation of the 60 percent of the total amount of applicable receivables initially paid to the HCF.

“Good claims” are those filed with complete documentary requirements that have been determined to be valid and worthy of payment, the state-run medical insurer said.

Should there be a need to recover un-reconciled amounts under the DCPM, Philhealth said it may send demand letters and/or “exhaust all legal avenues, including the filing of criminal charges.”

It said it may also suspend payments under the DCPM “for recurrent non-compliance to standards of care, presence of indication of fraud or for any other reason deemed relevant by Philhealth.”

The insurer said HCFS interested to participate in the DCPM must submit an accomplished “undertaking” that can be downloaded from the Philhealth website. It must be duly signed by the HCF owner and/or medical or hospital director “subject to the concurrence of Philhealth.”

Last month, Philhealth said it received a total of three million claims from PHAPI member-hospitals from January to December 2020. The insurer said 87 percent of these claims had been paid amounting to P25 billion while five percent (amounting to over P1 billion) are in different stages of processing.

However, about eight percent of total claims received, estimated to cost around P2.4 billion, were either denied payment or returned to hospitals due to “deficiencies and/ or violations of existing policies and guidelines.”