MANILA, Philippines — The Philippine Health Insurance Corp. (PhilHealth) said that P4.499 billion in return-to-hospital (RTH) claims accumulated in 2024 were not resubmitted to the state insurer for processing and payment.
During the House Good Government and Public Accountability Committee's hearing on Thursday, January 22, PhilHealth Senior Vice President Renato Limsiaco explained that hospitals failed to return the 316,557 RTH claims to the state insurer by the end of 2024.
“This figure, 2.174 million claims, under RTH as presented — these are the claims that weren’t returned to PhilHealth, not refiled to PhilHealth as of Dec. 31, 2024,” he said in a mix of English and Filipino, the total covering the years 2017 to 2024.
In a presentation, he explained that the top reasons for RTH claims include missing documents and clerical errors, which led to no reimbursements to hospitals.
For RTH claims, hospitals need only to comply with requirements or appeal to the state insurer for the claim to be considered valid, potentially leading to reimbursement for treatments or procedures covered under benefit packages.
The good government panel conducted the inquiry into PhilHealth’s budget, probing the large volume of RTH and denied claims. The panel also raised concerns about reports of hospitals closing due to delays or PhilHealth's failure to reimburse claims.
PhilHealth Chief Operating Officer Eli Dino Santos admitted the existence of late payments and possibility of health care facilities closing down because of their lack.
“We admit that there are late payments, there are claims that are returned to hospitals, there are denied claims,” he said.
“I’m sure that there are hospitals that are probably suffering from the denied claims,” he added.
Santos also mentioned that only claims that are “ready for processing and payment” will enter PhilHealth’s system, as it will flag those that are non-compliant.
Rep. Gerville “JinkyBitrics” Luistro (Batangas, 2nd District) said this is “disadvantageous” to hospitals and urged PhilHealth to simplify the required documents by making forms “user friendly” to avoid the claims.
Meanwhile, PhilHealth President Emmanuel Ledesma said they see several reasons that make it difficult for them, among them are the lack of personnel.
“I think there are a number of reasons, first is the shortage of personnel in PhilHealth. For example, there is a lack of lawyers, finance people,” he said, which is why they plan to increase their staff.
He added that the state insurer is “trying to be as lenient as possible” with the claims, but they are concerned about the Commission on Audit’s strict requirements (COA).
“It’s actually a very difficult balancing act for us because we hear all the stories of hospitals closing and all that,” Ledesma said.
While recognizing that P4.499 billion equates to several procedures unreimbursed, Ledesma argued it is only 2% of the total claims they received in 2024. He said 85.4% of the claims have already been paid.
The PhilHealth revealed at a previous committee hearing that there are P59.6 billion in combined RTH and denied claims from 2018 to 2024, excluding those from previous years.