PhilHealth belies owing hospitals billions of pesos

PhilHealth defined “in process” claims  as those with a vourcher for payment (Photo: Philippine Health Insurance Corporation/Facebook)

MANILA — The Philippine Health Insurance Corporation (PhilHealth) has belied allegations that it owes a number of hospitals some PHP7 billion to PHP9 billion in unpaid claims, calling the figures “erroneous and inaccurate”.

The government-owned and -controlled firm was reacting to statements made over radio station DZMM on May 8 by Dr. Rustico Jimenez, President of the Private Hospitals Association of the Philippines, Inc. (PPHAP), that Philhealth owes 15 PPHAP members some PHP7 billion to PHP9 billion in unpaid claims.

In a media statement released on Saturday, PhilHealth said based on its records, claims that are still “in process” for the period 2014-2018 totals only PHP50.85 million, or only 0.73 percent of the figures allegedly owed by PhilHealth to a number of hospitals.

PhilHealth defined “in process” claims as those with a voucher for payment.

It said for the same 2014-2018 period, there were 7,602 claims that were denied payment, while another 10,714 claims were returned to their respective hospitals “for compliance”.

“We immediately looked at the claims profile of a randomly chosen 12 hospitals in his list (as the others are with similar names still needing clarification from Dr. Jimenez) and found out that PhilHealth has paid them a total of PHP3.75 billion already for the period 2014 to 2018,” the PhilHealth statement read.

“Summing up PhilHealth’s payments of PHP3.75 billion and another PHP50.85 million in impending payments for in-process claims on record, less those already denied payments and returned-to-hospital claims (7,602 + 10,714 claims = 18,316 claims x P10,000 Average Value Per Claim = P183.2 million) quickly gives us an idea how overly bloated PHAPI’s claims are against the state health insurance agency,” the statement further explained.

PhilHealth also slammed Jimenez’s allegations that PhilHealth’s e-claims system has been delaying reimbursements to hospitals.

“Our Corporate Dashboard shows that we are paying hospital claims at an average of 50 days nationwide, with the shortest average claims processing time at 38 days for those submitted through third-party solutions providers under the new system being criticized by the PHAPI,” it said. “By law, PhilHealth has 60 calendar days to process and pay hospital claims.”

According to the PhilHealth statement, its E-Claims Submission System aims to reduce the turn-around-time and improve operational efficiency in the processing and payment of claims.

It said the new online system enables the encoding of claims information in the hospital systems, and submission online via PhilHealth Web Service, and provides institutional healthcare providers with a facility to view the status of their claims online.

To resolve the issue, PhilHealth said it would come up with a reconciliation portal for its partner hospitals “to readily provide them with a summary of their good, pending, denied, and in process claims”

“This is an added feature that will promote better efficiency and transparency,” it said.

It would also form a task force to review and expedite payments of unpaid claims, “if any”.

“We shall be looking into the claims data not just of PHAPI members but of all our accredited facilities in the government and private sectors to see if there are weak areas that we need to improve on, and other areas as well to continue building our strengths on,” PhilHealth said. “We also call upon our hospital partners to come to our regional and local health insurance offices, so together we can check and reconcile our records and resolve claims issues through open dialogue and compliance”.