Philhealth only pays ‘good’ claims; commits processing ahead of prescribed timeframe

THE Philippine Health Insurance Corporation (Philhealth) has assured its accredited health care providers that it is committed to paying claims that are without deficiencies and compliant to all pertinent policies and requirements of the program.

This was reiterated by the state health insurer amid concerns of the Private Hospital Association of the Philippines, Inc. (PHAPI) over the supposed nonpayment of claims to their member hospitals amounting to P6-B. The Agency clarified that the issue was not presented in the proper perspective as the said hospital association only highlighted the unpaid portion and downplayed that a total of P25-B has been paid in CY 2020.

Philhealth said that based on records, it received a total of three million claims from PHAPI member hospitals from January to December 2020, 87 percent of which had been paid amounting to P25-B, while 5 percent amounting to over P1-B are in different stages of processing.

However, about 8 percent of total claims received, estimated to cost around P2.4-B, were either denied payment or returned to hospitals (RTH) due to deficiencies and/or violations of existing policies and guidelines. Among the common reasons of RTH are unavailability/incompleteness/ inconsistency/unreadability of required documents, other documents being required, discrepancies in entries, Claim Form 2 not properly accomplished, and Claim Form 4 with errors, among others.

On the other hand, claims are usually denied due to non-compliance to standard of care (system), filing beyond the 60 days statutory period, late refiling, and non-compensable cases, among others.

“No less than the Filipino people expect us to be prudent in our dealings especially where their funds are involved, this is why we take great pains seeing to it that each and every claim that we pay are consistent with applicable laws and Program regulations,” Philhealth President and CEO Atty. Dante A. Gierran asserted, adding that as a state insurer, Philhealth is bound by the auditing rules of the Commission on Audit.

The Philhealth Chief also recognized the difficult situation being faced by many facilities especially in the midst of the pandemic, saying that “we are committed to pay good claims, but we are bound by law to properly act on deficient ones.” He even guaranteed quicker processing for good claims, citing latest performance record of 39 days on national average against the 60 days provided for by law.

Gierran added that the issue is best addressed through dialogues and reconciliation of records to put things into proper perspective. “Bukas po ang aming tanggapan sa lahat ng rehiyon para mag-reconcile po tayo ng ating claims records. Nakahanda kaming tulungan sila na makapag-comply sa mga polisiya para mabawasan kundi man maiwasan na ang denied o pagbabalik ng claims sa mga ospital.”

NEW NHMFC PRESIDENT. Mr. Carlo Luis P. Rabat (right) takes his oath before Department of Human Settlements and Urban Development (DHSUD) Secretary Eduardo Del Rosario as the newly-elected President of the National Home Mortgage Finance Corporation (NHMFC). Mr. Rabat, whose thrust is on the development of housing programs, served as mayor of Mati City, Davao Oriental from 2013 to 2019 and as the city’s Vice Mayor from 2010 to 2013.