PhilHealth told to refund members P325-M in unclaimed benefits

The Commission on Audit (COA) has tasked the Philippine Health Insurance Corporation (PhilHealth) to immediately refund the unclaimed health benefits of its members totaling P325.214 million.

“Member-claimants were deprived of the full health benefits due to them, because unclaimed health benefits returned by various Institutional Health Care Providers (IHCPs) in the amount of P325.214 million as of December 31, 2014 remained in the custody of PhilHealth,” the commission said in an annual audit report published on its website.
 
“We recommend the immediate refund of the unclaimed benefits to the members and the completion of the refund process be time-bound. It is further recommended that a special team be created for the purpose,” the COA said.

PhilHealth is a tax-exempt government-owned and controlled corporation attached to the Department of Health for policy coordination and guidance. It is mandated by the government to ensure the success of the National Health Insurance Program in providing coverage for all Filipinos.
 
Prior to implementing the “All Case Rate Program” in 2014, PhilHealth paid the IHCPs more than what the amount deducted from the medical bills incurred by PhilHealth members, the commission noted.

The difference between what was deducted by the IHCPs and total amount paid by PhilHealth is considered as “unclaimed benefits” and must be returned to the claimants a Notice of Benefit Payments (NBP), which the claimants can present to any PhilHealth office as a requirement for the refund, it said.

Based on records as of December 31, 2014, at least 266 IHCPs had already returned a total of P322.286-million of unclaimed health benefits, the commission said, noting that PhilHealth has exerted minimal effort to refund its members.
 
“Comparison of the amount of refunds to member-claimants with the remittances made by the IHCPs disclosed that despite the receipt of funds corresponding to the unclaimed benefits, the amount refunded to member-claimants was very minimal,” the COA report read.
 
Of the P89.355 million remitted by the IHCPs in 2014, PhilHealth only managed to the issue a refund of P365, the commission noted.
 
The commission said “the circumstances was no different for CYs 2013 and 2012,” in which, of the P121.190 million and P66.417 million remitted by IHCPs respectively, only P150,620 and P109,917 were refunded.

Not a priority?
 
“The accumulation of unclaimed benefits was an indication that PhilHealth Management had not given priority for its refund which was disadvantageous to the affected members. PhilHealth is duty bound to give the full health benefits due to the members in return to the health insurance premium the members paid,” the COA said.
 
“Further, the agency’s mandate of providing health care services to Filipinos, especially to the segment of the population who cannot afford such services could not be completely achieved if the unclaimed benefits were not fully refunded to the rightful members,” it reminded PhilHealth.
 
In a letter to COA, however, PhilHealth management said all the unclaimed refunds were already turned over to its Benefits and Development Research Department (BDRD) for processing as of October 2014, but the system disapproved many of the claims due to incomplete documentation.
 
PhilHealth said follow-ups with the regional offices were already done, but the offices in Region VIII said files could no longer be recovered after Typhoon Yolanda hit the region in November 2013.
 
PhilHealth further told the commission that a list of unclaimed refunds covering 14,000 members was already published on the agency’s website as well as in a national broadsheet last March to inform the members about the balances they can claim.
 
In a June 9, 2015 letter, PhilHealth president Alex Padilla assured the commission that the agency is doing its best to finish processing the unclaimed benefits.
 
“As the BDRD attempts to organize and reconcile all documents on unclaimed refunds… rest assured that PhilHealth commits to ensure that those members with unclaimed refunds will get their money back. The Corporation is doing its utmost best to get things done in the most efficient and effective manner,” Padilla said. – VS, GMA News