SUMMARY
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MANILA, Philippines – The Philippine Health Insurance Corporation (PhilHealth) returned to hospitals or rejected thousands of claims amounting to billions of pesos, according to the 2022 reports of the Commission on Audit (COA).
Albert Domingo, PhilHealth’s new spokesperson, attributed many of these rejected claims to hospitalizations due to the coronavirus pandemic.
Domingo explained: “So a lot of those returned-to-hospital and denied claims somehow have deficiencies when it comes to those requirements. Recently, when we analyzed these RTH claims, most of them could be traced back to the peak of the pandemic in 2020-2021. As the COA report properly cites, PhilHealth guidelines kept on changing.” (READ: Amid raging pandemic, PhilHealth took 7 months to issue circular on COVID-19 benefits)
In the COA report, the National Kidney and Transplant Institute said that it was difficult keeping up with PhilHealth’s changing guidelines, sometimes changing the guidelines while the claims were still being processed.
Domingo acknowledged this challenge, and attributed it to the rapid evolution of science and understanding of how COVID-19 spread during the early days of the pandemic.
“We know now that the antibody test is not something that you use to screen. You use it to check on the status. Now it’s clear, we take it for granted, but at the time it wasn’t so sure. So that was the background. Now, of course, you have to save lives. The doctors have to keep on acting, the hospitals have to keep on delivering the services, and then somehow costs are incurred, and someone has to pay the bill. Here come the claims,” emphasized Domingo, who also serves as PhilHealth’s vice president for primary care.
Fortunately, hospitals have a 60-day window from July 5 to re-file their returned claims or appeal their rejected claims.
Domingo clarified: “Hospitals have 60 days from July 5, which is the date of publication, to reapply, clarify, or adjust their claims. We’re hoping that this will resolve a lot.”
The Commission on Audit flagged a total of at least P1 billion in return claims from specialty hospitals in 2022, including:
- Philippine Children’s Medical Center (P200.277 million)
- Lung Center of the Philippines (P542.965 million)
- National Kidney and Transplant Institute (P243 million)
- Philippine Heart Center (P110 million)
To date, at least P500 million of these claims remain unpaid.
Domingo said that PhilHealth had started coordinating with the hospital administrations to expedite the processing of return-to-hospital claims.
In addition to resolving backlogs, PhilHealth adjusters are working closely with hospitals to ensure their compliance with PhilHealth guidelines and processes to prevent further accumulation of pending claims in the coming years.
Domingo further explained: “This adjuster, that is the role of the Benefit Administration Section, the BAS. So each and every PhilHealth Regional Office…[has a] PhilHealth Reach Out Program. They have nothing else to do except to literally reach out to the health facilities in their particular regions so that fees are minimized.”
What claims can be reimbursed?
According to PhilHealth Circular 2023-0001, claims with suspected cases managed as COVID-19 regardless of RT-PCR tests, and with admissions from April 15, 2020 to June 18, 2021, shall be reimbursable as COVID-19 case “in accordance with the applicable inpatient COVID-19 packages.”
Claims for suspected cases, managed as COVID-19, even with a negative RT-PCR, admitted between June 19, 2021 and October 30, 2021, may also be reimbursed.
Meanwhile, claims with a negative RT-PCR result, regardless if patient is managed as COVID-19, with admissions starting October 31, 2021, may also be reimbursed.
Read here the full memorandum on what claims can be re-filed or appealed:
– Rappler.com
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