Sen. Grace Poe reiterated her call to the Philippine Health Insurance Corp. (PhilHealth) to speed up payment to public and private hospitals and shun unnecessary and delaying procedures that impair the ability of healthcare institutions to carry out their crucial function.
The senator said that PhilHealth must do all to address hospital claims it refuses to pay as well as the so-called ‘return-to-hospital (RTH) claims’ which threaten the viability of these hospitals.
The Commission on Audit (COA) report on the Philippine Children’s Medical Center (PCMC) showed that PhilHealth denied a total of 1,641 claims from the government-run hospital amounting to P22.98 million as of Sept. 30, 2020 while RTH claims amounted to P11.60 million representing 683 claims. RTH claims are sent back to hospitals as PhilHealth deems they still ‘lack certain requirements.’
In 2019, PhilHealth denied 1,595 claims from PCMC amounting to P15.31 million.
The COA report said PCMC claims that PhilHealth denied increased by 126 percent from 2019 to end of September 2020 and the hospital’s loss arising from it amounts to P34.59 million.
For the National Kidney and Transplant Institute, the COA said PhilHealth denied 2,387 claims worth P30.31 million and the RTH claims amounted to 15,061 worth P122.81 million.
The COA said that PhilHealth also denied 2,432 claims from the Philippine Heart Center worth P38.92 million and its RTH claims amounted to 1,475 worth P32.25 million.
“These are just the claims of three government hospitals. Private hospitals lament the same experience. We are in the middle of a pandemic and it is unconscionable that hospitals are not getting paid for services rendered and medicine or treatments administered. Delayed payments are equally unacceptable,” Poe said.
According to the COA reports on the three government hospitals, among the reasons for rejecting the claims were ‘unpaid premium contributions’ and violations of PhilHealth circulars such as filing beyond 60 days, confinement was less than 24 hours, and the doctor who treated the patient was not accredited by PhilHealth.
“Hospitals facilitate the healing and recovery of our sick citizens. They expect PhilHealth to step up its efforts without letup amid the health crisis,” Poe said.
According to COA, there are still 4,953 sets of PhilHealth agent receipts that are unaccounted for and some agent receipts were even issued to those who have already lost their PhilHealth accreditation.
“It’s been a year since numerous PhilHealth issues and the supposed mafia that exists in the organization resurfaced. Despite the change in leadership, it is unfortunate that we are nowhere near resolving the extent of PhilHealth’s problems,” Poe lamented.
In the 2020 COA report, PCMC said its billing and claims division has been judiciously following the guidelines of PhilHealth and blamed the denied and RTH claims on “instantaneous changes in the PhilHealth evaluation of claims without further basis on circulars and policies and some technical glitches in the PhilHealth system.”
“Hindi tama na hindi binabayaran ang mga ospital at hindi makatarungang pabalik-balikin ang mga tauhan nila na umaasang makakakolekta. Ang mga ospital at mga medical frontliner ang magtatawid sa atin sa pandemyang ito. Dapat bayaran na sila ng PhilHealth,” Poe stressed.