P6-B unpaid claims to hospitals? PhilHealth says amount is returned, denied claims due to deficiencies

The Philippine Health Insurance Corp. (PhilHealth) on Saturday clarified reports that the state health insurer has some P6 billion in unpaid obligations or reimbursements to private hospitals, saying the amount represents returned or denied claims due to deficiencies and non-compliance.

Early this week, the Private Hospitals Association of the Philippines claimed that PhilHealth failed to pay its members P6 billion of reimbursements, forcing some hospitals to downsize to minimize their expenses.

In a statement posted on its Facebook page, the agency said, “Cognizant to the situation, PhilHealth ensures that it is paying its obligations to its accredited health care providers within and even way faster than what was required by law, provided that the claims comply with existing policies and guidelines, pursuant to strict auditing rules of the Commission on Audit.”

The PhilHealth said it has received P91.06 billion worth of claims from PHAPI member-hospitals between 2018 and 2020, representing 9.2 million claims.

Of the said amount, 563,000 claims worth P5.6 billion were returned or denied “due to deficiencies and various non-compliance to policies and guidelines.

“From 9.2 million claims received/refiled, 6% were returned-to-hospital (RTH) or denied due to deficiencies,” the PhilHealth said.

The state insurer explained why claims were being returned to hospitals or denied. The reasons are as follows:

RTH

• required documents are unavailable/incomplete/inconsistent/unreadable
• requiring other documents
• discrepancies (in entries)
• Claim Form 2 is not properly accomplished
• with errors in Claim Form 4

Denied

• non-compliance
• non-compliance to standard of care (system)
• filed beyond 60 days statutory period
• late refiling
• case is not compensable

Hospitals with RTH claims have 60 days to refile, while denied claims can be contested through the filing of a motion for reconsideration.

“PhilHealth is bound to pay claims of partner hospitals that are compliant to the existing policies, implementing Rules and Regulations and COA rules on reimbursement,” it said.

It added that it is “actively conducting meetings and dialogues on a regional and local levels to reconcile claims records with individual health care providers to address operational and RTH issues.

The state insurer said it even employed accounts officers called “Project Reach Out” to monitor hospital claims.

The PhilHealth said it is assisting providers to better comply with existing policies to minimize if not to eradicate RTH and denied claims. -MDM, GMA News