PhilHealth exec: Several remedies available for hospitals with denied claims

Hospitals whose patients’ claims were denied by the Philippine Health Insurance Corporation (PhilHealth) can avail of several remedies to recover their losses.

“There are several remedies for denied claims,” PhilHealth vice president for Corporate Affairs Shirley Domingo told GMA News Online.

“First an MR (motion for reconsideration) at the level of our regions. If still denied, [final] appeal to the board,” Domingo said.

The PhilHealth official was asked who will shoulder the P8.3 billion worth of denied hospitals claims since January 2020, after Senator Nancy Binay raised concern that patients will be asked to pay their hospital bills and then they will be referred to PhilHealth to process their own claims because of the denied claims. 

“Our regions are in constant dialogues with hospitals, especially the staff in charge of PhilHealth claims. They are oriented on these processes,” Domingo said.

Under PhilHealth Circular No. 3, series of 2008, hospitals whose benefits claim has been denied or reduced can file for a motion for reconsideration with the PhilHealth Regional Offices (PROs).

A final appeal can be filed if the motion for reconsideration has been denied by the PRO.

At a Senate budget hearing, PhilHealth president and CEO Dante Gierran disclosed that there are P8.3 billion worth of denied claims from January 1, 2020 to October 6,2021.

Gierran said hospitals can still appeal PhilHealth’s denial of their patients’ claims.

Health Secretary Francisco Duque III, ex-officio chairman of the PhilHealth board, explained that the P8.3 billion mentioned by Gierran was just an “indicative figure.”

The P8.3 billion denied claims was an accumulated amount from 1,283 member-hospitals.

The Health chief said the good claims, which amounted to P130 billion released by PhilHealth for reimbursements, is still huge compared to the P8.3 billion denied claims. — RSJ, GMA News