PhilHealth: P4.4B 'return to hospital' claims unappealed

At least P4.4 billion worth of claims returned by the Philippine Health Insurance Corporation (PhilHealth) to hospitals due to lack of requirements were never returned to PhilHealth for reconsideration, PhilHealth Senior Vice President Renato Limsiaco said Wednesday.

Limsiaco made the disclosure during the questioning of Batangas Rep. Gerville Luistro during Wednesday’s House good government and public accountability probe on PhilHealth’s unpaid P59.6 billion worth of unpaid hospital claims.

“P4.49 billion po ang RTH (return to hospital) [claims] as of December 31, 2024,” Limsiaco said.

“What are the reasons bakit hindi sila nag-comply, hindi nila binabalik sa PhilHealth para makaclaim sila? E paano sila makakaclaim kung hindi nila aayusin ‘yung kulang at ibabalik sa PhilHealth [ang claim]?,” Luistro asked.

(Why are they not returning these claims so they can be paid? How can they secure claims when they refuse to fix the requirements needed?)

PhilHealth Chief Executive Officer Emmanuel Ledesma did not respond categorically and instead said that PhilHealth is currently being aggressive in reconciling hospital claims for payout.

He added that through this effort, they discovered that there are hospital owners who are not aware that their initially denied claims for payout due to lack of requirements are not being appealed for reconsideration.

Further, Ledesma said that the P4.49 billion, or those claims already let go by hospitals, is just 2% of the total returned claims to hospitals.

“Ma'am [Luistro], we hear you. It is a big number. But maybe to put it in context, if you don't mind, Mr. Chair and Honorable Committee, the percentage of total claims of RTH is less than 2%. So I know the number is big, ma'am, but if you look at it in percentage terms, that's less than 2%,” Ledesma said.

Luistro, however, stressed that P4.49 billion is no pittance.

“That's still a huge amount. I just want to share my apprehension in conclusion of my interpellation because we have received reports that because of [the] delay in the payment of claims, some hospitals have ceased in continuing the certain services, some fully closed already,” Luistro said.

Luistro cited the case of a private hospital in her hometown of Mabini, Batangas, which closed down due to PhilHealth’s failure to pay the said hospital’s claims on time.

“The reason why they shut down is because of the delay in the payment of PhilHealth. That's from the point of view of one of the stockholders. Sana wala nang ibang hospital na ganito. Because you know what? That is the only private hospital in my hometown. And when it closed, it really affected the healthcare system in my hometown,” Luistro said.

“And it is hard to understand why PhilHealth, the partner of the government in implementing this mandate on the healthcare system, is the reason why the hospital institutions will be closing,” Luistro added.

—VAL, GMA Integrated News