PhilHealth circulars complicate hospital reimbursements

MANILA, Philippines — A series of circulars issued by the Philippine Health Insurance Corp. (PhilHealth) complicated the process for reimbursement claims since last year, resulting in the piling up of unpaid hospital claims amounting to P86 billion, which House leaders said could cause the collapse of the country’s health care system.

Officials of both the Philippine Hospital Association (PHA) and the Private Hospitals Association of the Philippines (PHAPi) gave this startling figure during the recent hearing conducted by the House committee on health headed by Quezon Rep. Helen Tan.

Dr. Jaime Almora, PHA president, and Dr. Gerry Gonzales of PHAP, said they have P86 billion worth of claims with the state-run health insurer from January 2020 to June 2021, and that PhilHealth’s series of circulars – issued several months apart – complicated the process.

“We are requesting for the simplification of the PhilHealth’s policies, because these kinds of policies may lead to the collapse of the whole hospital system, and the ultimate losers are the patients,” Almora warned.

PhilHealth admission

PhilHealth president and CEO Dante Gierran acknowledged the problem with the original circular they issued in April 2020, which they revised in November of the same year, with two more released in May and June this year, resulting in more confusion.

The memorandum delved on the supposed “benefit packages” for COVID-19 patients, more particularly those involving “probable” and “confirmed” and severe illnesses or cases, in which case their hospital bills are shouldered by PhilHealth.

“I would certainly recommend to the board, being the highest authority in the corporation, to have this matter be taken into consideration for favorable action,” Gierran told legislators at the hearing.

The same admission was made by PhilHealth vice president Eli Dino Santos.

“I admit, it cannot be denied that there is delay in this. There are just so many reasons and we will not provide excuses. It’s just that there were several circumstances that went beyond our control. It was already late when the circular was published,” Santos said.

“We will bring this up to the Board for possible modification on our next meeting, which is on Aug. 25. We will bring this (policy) back to the Board for their reconsideration,” he added.

Lawmakers alarmed

Tan’s colleague Rep. Estrellita Suansing of Nueva Ecija lamented that the issuance of a circular last June that carried out a “retroactive effect” on claims of up to November or even April 2020 is “not at all good.”

Zambales Rep. Cheryl Deloso-Montalla was more vocal and categorical, saying: “We don’t want our health care providers (both public and private hospitals) to go bankrupt.” She urged PhilHealth to hire more lawyers for their legal division.

Reps. Tan, Suansing, Montalla and Ma. Lourdes Arroyo of Negros Occidental (a PWD herself), among many others, have raised concerns that the PhilHealth circulars may result in the collapse of the country’s entire health system at the height of the global pandemic.

Denial of payment

Almora explained that out of the P86 billion in unpaid claims, P25.6 billion worth are now being processed. However, P46.6 billion worth of claims have been returned to the hospitals for various reasons like documentary deficiencies, while P13.8 billion has been flatly denied by the PhilHealth.

“Arbitrary denial of payment, resulting in losses to hospitals is not only unlawful, but also morally wrong,” said Almora. “If we look at the denied claims alone, there is P13.8 billion comprising 619,956 claims.”

“It would translate to P13.8 million per hospital (based on 1,000 hospitals) that was not paid, that was denied to the hospital,” he said.

Gonzales echoed the same sentiment, saying: “Weekly, we even look at our expenses if we can pay the salaries of our health workers. We hope PhilHealth can resolve these issues with the private hospitals.”

‘Upcasing’ probe

Meanwhile, the PhilHealth is investigating reports that some hospitals are “upcasing” admissions to get bigger reimbursements from the state insurer.

“Sometimes, a patient is hospitalized for a simple cough and cold or another illness, but logged as a COVID case to increase the reimbursement claim from PhilHealth,” Philhealth spokesperson Shirley Domingo said in Filipino during a radio interview. – Mayen Jaymalin