PhilHealth clarifies role over claims of patients

CEBU, Philippines — The Philippine Health Insurance Corporation (PhilHealth) has clarified its role over claims of patients admitted in the hospital.

PhilHealth has issued the clarification in reaction to a recent social media post that went viral regarding the death of a Cebuana’s mother.

While diagnosing a patient is within the control of the attending physician or a doctor, PhilHealth, as the state health insurance provider, covers a portion of the hospitalization cost of patients diagnosed and managed in an accredited hospital.

The viral post said that though it was a natural death, it was still indicated as suspected COVID-19 allegedly for the purpose of a PhilHealth claim of P160,000.

“Ni-insist jud ko sa health worker ngano ibutang ug suspected nga di man Covid akung mama. Mao diay kay ang doctor naa diay ni sila ma-claim sa Philhealth,” part of the viral post said.

The death certificate though did not indicate as such and was told the funeral homes accordingly made such discrepancy of indicating as suspected COVID-1 positive.

The Freeman tried to reach the person who lost her mom last July and posted the incident on Facebook but to no avail.

The post has already been taken out already while a relative told The Freeman their family just wants to keep silent to avoid any controversy.

“As we have stated in our last regional statement, PhilHealth is assuring the public that claims received from accredited health care institutions are duly reviewed by medical doctors in the Regional Office’s Benefits Administration Section even before this pandemic,” said PhilHealth-7 public relations officer Dina Cinchez.

PhilHealth medical doctors’ basis in processing the benefit claims related to COVID-19 is the clinical practice guidelines set by the Philippine Society for Microbiology and Infectious Diseases (PSMID).

Claims with incomplete requirements or discrepancies are returned to hospitals for compliance, while claims determined to be invalid due to an absolute deficiency or unmet requirement are denied.

As of August 31, 2020, PhilHealth 7 has already paid 515 in-patient COVID-19 claims totaling to P109.9 million and P32.6 million for 6,141 claims on SARS-CoV-2 (RT-PCR) testing.

Benefits are case-based and not a uniform benefit payments that can be availed.

 “The amount that PhilHealth covers is based on the doctor’s diagnosis as reflected

on the claim documents filed,” added Cinchez.

So far, there were also 359 claims which were returned to hospitals and 65 others were being denied.

As reported earlier, some claims in the region were returned to hospitals as certain requirements need to be complied based on the adjudication and validation of PhilHealth’s Benefits Administration Section.

Returning the complied claim to PhilHealth may result in the reversal of the deficiency into a good claim while non-compliance may result in the denial of the claim.

 Denied claim is a claim that has been determined to be invalid and unworthy of payment/reimbursement due to an absolute deficiency that cannot be remedied through Return to Hospital (RTH) or due to a finding of an unmet requirement.

Claims that can be denied include inconsistent data, non-compliance to standard of care, and operation/service is not allowed in the facility which is common on claims for the RT-PCR/swab testing as they are not accredited with PhilHealth in providing such benefit package.

The Department of Health (DOH) issues licenses to health care institutions and provides certification to testing laboratories/facilities.

All DOH-certified facilities may apply for accreditation to PhilHealth in order for members to avail of the benefit package as health insurance coverage. — GMR (FREEMAN)