PhilHealth accumulated P59.6B in denied, returned claims to hospitals since 2018
MANILA, Philippines — For the past seven years, hospitals across the Philippines have been left waiting for P59.6 billion in payments from the Philippine Health Insurance Corp. (PhilHealth) for claims that have been denied or sent back for compliance.
The House Committee on Health learned about this during a hearing on Wednesday, January 15, when PhilHealth was grilled for billions worth of accounts payable despite having a large reserve fund.
PhilHealth Senior Vice President Renato Limsiaco presented the committee with figures showing that in 2024 alone, there were 483,000 denied claims amounting to P4.7 billion.
Meanwhile, from 2018 to 2023, denied claims totaled 3.017 million, valued at P32.4 billion.
This brings the total to P37.1 billion in denied claims for the past seven years, including 2024.
Denied claims now account for three-fifths of the P59.6 billion in claims that hospitals could have received. These claims are denied only if PhilHealth’s assessment determines them to be “invalid” or “unworthy” due to a deficiency or unmet requirement that could no longer be remedied.
The Department of Health (DOH) explained that most of these claims were denied because hospitals failed to file them within 60 days, a rule stipulated in the law and PhilHealth’s circulars.
The remaining 37.75% consists of return-to-hospital (RTH) claims, which contain clerical errors and are sent back to healthcare facilities for correction.
Once the errors are addressed, these claims are considered “good claims” and are then paid by PhilHealth.
Limsiaco told the panel that from 2018 to 2024, there were a total of P22.5 billion in return-to-hospital (RTH) claims.
In 2024 alone, 304,082 RTH claims amounted to P4.2 billion, while from 2018 to 2023, 1.739 million RTH claims totaled P18.3 billion.
The P59.6 billion worth of unpaid claims, however, does not include those from the years before 2018.
At the same time, the DOH said that some of these claims are not classified as accounts payable by PhilHealth. This explains why, when initially asked, Limsiaco mentioned that only P21 billion needed to be settled.
‘Ayuda’ to compensate PhilHealth’s inefficiency
Rep. Stella Quimbo (Marikina, 2nd District) expressed frustration over PhilHealth’s failure to reimburse hospitals, noting that this not only impacts their operations but also affects patients seeking coverage from the state insurer.
“We need to expand beyond indigent patients because of the situation with PhilHealth, where we are very strict with denied and RTH claims and other issues. This is squeezing the liquidity of hospitals, forcing them to close. That’s the practical effect on the people,” she said in a mix of English and Filipino.
The lawmaker added that PhilHealth’s inefficiency spending of its funds led to the creation of the Medical Assistance for Indigent and Financially Incapacitated Patients (MAIFIP), which she said has been criticized for serving as a donation or “ayuda.”
“So in the end, we get bashed to death because people are angry, asking why we keep giving out aid. We can’t say it’s because PhilHealth is so inefficient in making payments,” Quimbo said in a mix of English and Filipino.
She urged PhilHealth to revise its rules on RTH and denied claims to minimize them, telling the state insurer that the government should be “more customer-oriented.”
PhilHealth President Emmanuel Ledesma agreed. He mentioned that they received an opinion from the Office of the Government Corporate Counsel (OGCC) permitting them to reimburse hospitals even if they are late by 60 days.
It still, however, doesn’t consider the claims filed beyond 60 days.
DOH Assistant Secretary Albert Domingo said they proposed to PhilHealth management to extend the 60-day deadline when justified and to formalize this in a resolution.
While lawmakers acknowledged PhilHealth's increases in benefit packages for most case rates, and even more so for specific treatments and procedures for major diseases, they said these changes may not have much impact due to the rising cost of hospital bills in recent years.
Quimbo emphasized that a more effective and accurate costing approach is needed when adjusting case rates, ensuring that expanded benefit packages address more than just inflationary concerns.
The health panel also learned on Wednesday that PhilHealth could tap up to P759 billion from various funding sources, including its reserve fund and surplus, to cover benefit expenses.
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