PhilHealth answers delayed reimbursement allegations
MANILA, Philippines – The Philippine Health Insurance Corporation (PhilHealth) on Monday, May 26, pointed out inaccuracies in recent allegations against their reimbursements for private hospitals.
“There is no truth to the allegations of Dr Rustico Jimenez that due to mismanagement, PhilHealth owes P600 million to 600 private hospitals," PhilHealth president and chief executive officer Alexander Padilla said in a briefing Monday in Malacañang.
"What he gave us – his enumeration – was on 10 hospitals totaling P70 million, most of which are not even backlog claims.”
Jimenez, president of the Private Hospitals Association of the Philippines (PHAPi), cited PhilHealth's ongoing computerization as the cause of the delay in the reimbursements of around 600 hospitals nationwide.
In a radio interview, Jimenez supposedly enumerated 10 hospitals affected by the delay.
But Padilla on Monday pointed out the inconsistencies in Jimenez’ allegations, among them, the inclusion of a government hospital in the list, and a De Vera Hospital in Bulacan which Padilla said does not exist in Region 3.
He also explained there is no backlog in 4 hospitals in the list: San Juan de Dios Hospital in Pasay, Western Visayas Medical Center (government hospital), Ciudad Medical Zamboanga Hospital, and Virgen Milagrosa Hospital in San Carlos.
Processing of claims is still ongoing for the rest of the hospitals. See table below as provided by Philhealth:
|Hospital||Alleged PhP Backlog||Actual Status|
|San Juan de Dios Hospital, Pasay||P15 million||No Backlog. NCR South Branch has paid a total of
1,712 good claims equivalent to P26.72 million. The
turn-round time for claims processing in NCR South
Branch is now at 13 days
|Calamba Doctors Hospital||P15 million||There are 2,867 filed claims while 719 were returned to
hospital (RTH) or denied. The 719 claims will amount
to only P6 million. All other claims are being processed
|Western Visayas Medical Center
|P13 million||No Backlog. As of April 2014, the region has already
reimbursed 5,445 good claims in the amount of P77.97
million for Western Visayas Medical Center.
|Gingoog Sanitarium Misamis
|P7 million||All claims are still being verified and processed|
|Ciudad Medical Zamboanga Hospital||P 6 million||No Backlog. Per PhilHealth Region IX, the
hospital still has 2013 claims that were refiled
due to incomplete documents or
under-payment. For January 1 - May 15,
2014, the hospital filed a total of 2,268
claims, 1,138 are for check generation
while 764 good claims were already paid.
Only 38 claims are being processed.
|Virgen Milagrosa Hospital, San Carlos||P 6million||No Backlog. Per PRO I, there are 356
claims on process which translates to P3.2
|“De Vera Hospital” in Bulacan||P5 million||No such hospital in Region 3|
|San Pablo Doctors Hospital||P4 million||Per PhilHealth Region IV-A, there 542
claims that were returned to hospital (RTH)
or denied which translates to P4 million.
The alleged unpaid claim represents the
RTH or denied claims. All other claims are
|Alterado General Hospital||P4 million||Per PhilHealth Region XI, since year 2010,
Alterado General Hospital has only filed 87
claims and only 1 claim for 2014
amounting to P15,000
|St. Camillus Hospital. Davao Or||Delayed since Jan||Per letter of St. Camillus dated April 8,
they are requesting for reimbursement for
the months of March and April 2014 and
asking for advance payment (these are still
within the 60 day processing period and
advance payment is not allowed)
PhilHealth is the government's national health insurance program aimed at providing affordable health care to Filipinos.
Hospitals have 60 days from a patient’s discharge to file their claims to PhilHealth, Padilla explained. If filed beyond this period, or if documentation is incomplete, these claims can either be returned to hospital or denied.
PhilHealth, in turn, has 60 days to pay a good claim.
Below is the total return to hospital claims and total denied claims of PhilHealth for 2014, based on Philhealth data:
Returned to Hospital & Denied Claims
|Returned To Hospital
(incomplete documents / data)
- 60 days to refile their claim after RTH
and another 60 days for PhilHealth to
*estimates based on average value
(hospitalization is not compensable or
filed by the hospital beyond 60 days)
|37,358 denied claims
P386 million *
*estimates based on average value
per claim of P10,349
PHAPi considered not honoring PhilHealth membership of patients due to the delay but decided against the move after PhilHealth promised to pay them by the end of June, the Philippine Star reported.
Padilla asked Jimenez to stick to facts instead of accusing PhilHealth of fraud or theft.
Earlier, Jimenez slammed PhilHealth for having "the guts to give big bonuses to themselves" amid the reimbursement delays. (READ: Stop 'unreasonable' Philhealth premium hike, SC told we will stick to the facts)
But Padilla said PhilHealth is operating within the budget as set by law: “Our administrative cost is no way connected to our payment of reimbursements."
He also noted their payment for benefit reimbursements even increased as PhilHealth claims increased for the first quarter of 2014. A total of P16 billion has been paid to hospitals from January to March 2014 – bigger than last year’s P13 billion.
"PhilHealth has paid P1.35 billion every week in benefits or in reimbursements, compared to only P1.2 billion every week last year,” he said.
Meanwhile, investigation is ongoing for 8,000 cases of hospital claims that are either fraudulent or deemed fraudulent by PhilHealth in varying degrees.
The health department expects health insurance coverage of more than 90% for Filipinos by the end of 2014. This year, P35.4 billion have been allotted for health coverage of 14.7 million indigent families. – Rappler.com