Solons call Philhealth reasons for denying, delaying claims ‘mechanical’

Several lawmakers on Friday believed that the reasons why PhilHealth delayed and denied hospital claims were too "mechanical."

During the House Committee on Good Government and Public Accountability's hearing, Marikina Representative Stella Quimbo questioned if the reasons could be deemed as fraudulent acts.

"Nakalimutan mag-attach, etc. Wala nga doon... suspected fraudulent, which I believe is the most important reason kung magde-deny man kayo ng claim," Quimbo said.

(There's no suspected fraudulent act, which I believe is the most important reason why PhilHealth denies a hospital claim.)

In the same briefing, PhilHealth cited the following as the common reasons for claims ageing beyond 60 days:

• No value has been set for patient priority subgroup;
• No value has been set up for services covered in COVID testing claim;
• Without attached valid itemized billing;
• No value has been set for the flag indicating whether test kits have been donated or not;
• Without attached valid case investigation form;
• Without attached valid SARS-COV-2 claim summary form;
• Required document is unavailable/incomplete/inconsistent/unreadable;
• Filed beyond 120 days statutory period;
• No applicable entry found in the benefits library; and
• Double filing/same day confinement

Quimbo noted that looking at all of these reasons, there seems to be no reason "why the claims should age beyond two months."

She pressed PhilHealth if there was an indication of fraud.

"Isn't that an important reason for possible denial? Hindi po ba dapat pag magde-deny kayo ng claim, of course one, hindi siya nagmi-meet ng statutory requirements, but number two, it should be those suspected to be fraudulent," Quimbo said.

(If you will deny a claim, one reason is that they didn't meet the statutory requirements and number two, it should be suspected of being fraudulent.)

PhilHealth's Dr. Jonathan Ele specifically mentioned the double filing or same day confinement as a matter that could be considered as fraud.

"One patient, dalawang claim na sinubmit... There is a possibility na pwede pong hindi, there is a possibility of fraud po," Ele said.

This was echoed by Kabayan party-list Representative Ron Salo: "Napansin ko rin po lahat po ng reasons dito, wala pong kinalaman doon sa tinatawag na fraudulent claims."

(I have noticed that the reasons were not related to fraudulent claims.)

PhilHealth has been criticized over its unpaid claims to hospitals.

Philippine College of Physicians president Dr. Maricar Limpin had said that medical workers felt were are being mistreated as they lament the still unpaid claims of the state insurer to hospitals. — DVM, GMA News