PhilHealth starts medical prepayment review for claims

The Philippine Health Insurance Corporation (PhilHealth) has started to require a medical prepayment review for claims of its members seeking treatment in hospitals.

In an emailed statement, PhilHealth said it started prescribing a medical prepayment review for all admissions on March 1, 2019, as mandated by PhilHealth Circular 2019-002.

"Medical pre-payment review is a process that takes place prior to actual processing, wherein claims that are not compensable, as well as those that are not compliant to existing policies and standards on quality of care, will no longer be processed," the state health insurer said.

The policy, however, will not cover claims directly filed with PhilHealth and those involving confinements abroad.

It will also exclude the following, as their current required documentary requirements will still apply:

• Z-benefit packages
• Outpatient HIV/AIDS Treatment
• Outpatient Malaria Package
• Animal Bite Treatment
• TB-DOTS
• Antenatal Care Package
• Normal Spontaneous Delivery
• Maternity Care Package
• Newborn Care Package
• Subdermal Contraceptive Implant Package
• Intrauterine Device Insertion Package
• No-scalpel Vasectomy
• Resuscitation Package
• Referral Package

According to PhilHealth, the new system will be able to detect irregular practices such as over-utilization or under-utilization of services; the unnecessary use of diagnostic and therapeutic procedures; and the use of fake or misbranded drugs, among others.

"With this new policy, we aim to maximize our limited manpower and financial resources to promptly act on good and compliant claims," said PhilHealth acting CEO Dr. Roy B. Ferrer.

"This also saves much on time which translates to faster turnaround time for claims processing, and good health outcomes for our patients," he added.

The policy will require the use of Claim Form 4 (CF4), which summarizes pertinent clinical information of a patient or member during their hospitalization. —LDF, GMA News