PhilHealth clar­i­fies role over claims of pa­tients

The Philip­pine Health In­sur­ance Cor­po­ra­tion (PhilHealth) has clar­i­fied its role over claims of pa­tients ad­mit­ted in the hospi­tal.

The Freeman - - News - Cae­cent Noot Mag­sum­bol/GMR

PhilHealth has is­sued the clar­i­fi­ca­tion in re­ac­tion to a re­cent so­cial me­dia post that went vi­ral re­gard­ing the death of a Ce­buana’s mother.

While di­ag­nos­ing a pa­tient is within the con­trol of the at­tend­ing physi­cian or a doc­tor, PhilHealth, as the state health in­sur­ance provider, cov­ers a por­tion of the hos­pi­tal­iza­tion cost of pa­tients di­ag­nosed and man­aged in an ac­cred­ited hospi­tal.

The vi­ral post said that though it was a nat­u­ral death, it was still in­di­cated as sus­pected COVID- 19 al­legedly for the pur­pose of a PhilHealth claim of P160,000.

“Ni- in­sist jud ko sa health worker ngano ibu­tang ug sus­pected nga di man Covid akung mama. Mao diay kay ang doc­tor naa diay ni sila ma- claim sa Philhealth,” part of the vi­ral post said.

The death cer­tifi­cate though did not in­di­cate as such and was told the fu­neral homes ac­cord­ingly made such dis­crep­ancy of in­di­cat­ing as sus­pected COVID-1 pos­i­tive.

The Freeman tried to reach the per­son who lost her mom last July and posted the in­ci­dent on Face­book but to no avail.

The post has al­ready been taken out al­ready while a rel­a­tive told The Freeman their fam­ily just wants to keep silent to avoid any con­tro­versy.

“As we have stated in our last re­gional state­ment, PhilHealth is as­sur­ing the public that claims re­ceived from ac­cred­ited health care in­sti­tu­tions are duly re­viewed by med­i­cal doc­tors in the Re­gional Of­fice’s Ben­e­fits Ad­min­is­tra­tion Sec­tion even be­fore this pan­demic ,” said PhilHealth-7 public re­la­tions of­fi­cer Dina Cinchez.

PhilHealth med­i­cal doc­tors’ ba­sis in pro­cess­ing the ben­e­fit claims re­lated to COVID- 19 is the clin­i­cal prac­tice guide­lines set by the Philip­pine So­ci­ety for Mi­cro­bi­ol­ogy and In­fec­tious Dis­eases (PSMID).

Claims with in­com­plete re­quire­ments or dis­crep­an­cies are re­turned to hos­pi­tals for com­pli­ance, while claims de­ter­mined to be in­valid due to an ab­so­lute de­fi­ciency or un­met re­quire­ment are de­nied.

As of Au­gust 31, 2020, PhilHealth 7 has al­ready paid 515 in-pa­tient COVID-19 claims to­tal­ing to P109.9 mil­lion and P32.6 mil­lion for 6,141 claims on SARS- CoV- 2 ( RT- PCR) test­ing.

Ben­e­fits are case-based and not a uni­form ben­e­fit pay­ments that can be availed.

“The amount t hat PhilHealth cov­ers is based on the doc­tor’s di­ag­no­sis as re­flected on the claim doc­u­ments filed,” added Cinchez.

So far, there were also 359 claims which were re­turned to hos­pi­tals and 65 oth­ers were be­ing de­nied.

As re­ported ear­lier, some claims in the re­gion were re­turned to hos­pi­tals as cer­tain re­quire­ments need to be com­plied based on the ad­ju­di­ca­tion and val­i­da­tion of PhilHealth’s Ben­e­fits Ad­min­is­tra­tion Sec­tion.

Re­turn­ing the com­plied claim to PhilHealth may re­sult in the re­ver­sal of the de­fi­ciency into a good claim while non-com­pli­ance may re­sult in the de­nial of the claim.

De­nied claim is a claim that has been de­ter­mined to be in­valid and un­wor­thy of pay­ment/re­im­burse­ment due to an ab­so­lute de­fi­ciency that can­not be reme­died through Re­turn to Hospi­tal (RTH) or due to a find­ing of an un­met re­quire­ment.

Claims that can be de­nied in­clude in­con­sis­tent data, non- com­pli­ance to stan­dard of care, and oper­a­tion/ ser­vice is not al­lowed in the fa­cil­ity which is com­mon on claims for the RT- PCR/ swab test­ing as they are not ac­cred­ited with PhilHealth in pro­vid­ing such ben­e­fit pack­age.

The Depart­ment of Health ( DOH) is­sues li­censes to health care in­sti­tu­tions and pro­vides cer­ti­fi­ca­tion to test­ing lab­o­ra­to­ries/fa­cil­i­ties.

All DOH- cer­ti­fied fa­cil­i­ties may ap­ply for ac­cred­i­ta­tion to PhilHealth in or­der for mem­bers to avail of the ben­e­fit pack­age as health in­sur­ance cov­er­age. —

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