PhilHealth-7 assures: COVID-19 claims being verified

CEBU, Philippines —  PhilHealth-7 has assured the public that claims received from accredited health care institutions are duly reviewed by medical doctors of their Benefits Administration Section even prior to the COVID-19 pandemic.

In a statement, PhilHealth-7 said that claims with incomplete requirements or discrepancies are returned to hospitals for compliance.

It added that claims determined to be invalid due to an absolute deficiency or unmet requirement are denied.

As of August 31, 2020, it said, it 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.

As of the same date, there were 359 claims which were returned to hospitals, while 65 were denied.

“These claims are redirected back to the hospital or healthcare facility with instructions to comply with certain requirements (e.g. Claim Form 4 - Clinical Summary is not properly accomplished),” said PhilHealth-7 public relations officer Dina Cinchez.

Cinchez said returning the 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, 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 a benefit package.

Meanwhile, in light of the video statement of Cebu Governor Gwendolyn Garcia entitled “I just hope that we will be truthful and honest about things,” which came out late July this year, PhilHealth-7 said it has reached out to authorities in verifying possible cases of fraud wherein hospitals are allegedly taking advantage of PhilHealth’s benefit payment by making non-COVID-19 case appear as one to enable patients claim higher benefit coverage.

Cinchez told The FREEMAN that they had reached out to the Provincial Health Office to get more details on Governor Garcia’s inquiry but did not get any word so they proceeded to ask assistance from the PNP Criminal Investigation and Detection Group to verify some matters.

An investigation report from the PNP Criminal Investigation and Detection Group-Regional Field Unit 7 received by PhilHealth-7 on September 10 states that in relation the incident in Carmen, Cebu wherein a person was hospitalized due to stab wounds, “the victim died instantly due to multiple stab wounds but was not admitted to the hospital and did not undergo RT-PCR Test.”

It added that the report further reflects that “for the same period, [the health care institution] nearest to Carmen, Cebu has admitted nine patients of stabbing incidents. Accordingly, all the victims were subsequently released from the said infirmary after given appropriate medication without subjecting for RT-PCR Test.”

Cinchez said there was no claim for reimbursement from the facility where the patient was treated since the facility is not also accredited with PhilHealth.

She said, though, that even before Covid, Philhealth’s own doctors had been doing their own validations.

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.

“Even before Covid, naa gyud nay validation among mga doctors. Tan-awn ang mga claims and i-review man na sa among mga medical doctors if nisunod ba sila sa standard of care sa sakit. If kwestyunable siya, pwede man na sila mangayo og supporting document, like clinical chart ba sa patient. If fraudulent gyud siya, if kaduda-duda gyud, naay ground for fraud, i-refer na siya sa among benefit section to our legal office. Then among legal, mag-fact-finding pud na sila,” Cinchez said.

The Department of Health (DOH) issues license 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. — JMD  (FREEMAN)