PhilHealth vows payment of hospital claims

CEBU, Philippines —  The Philippine Health Insurance Corporation (PhilHealth) in Central Visayas has assured its accredited hospitals and medical facilities that it will pay its obligations.

It said it has funds to cover the claims it owes to hospitals following Acting Cebu City Mayor Michael Rama’s call.

“PhilHealth has assured accredited hospitals and facilities, time and time again, that it is committed to paying claims that are without deficiencies and compliant to all pertinent policies and requirements of the National Health Insurance Program,” the agency said in a statement.

Rama earlier appealed to the national government, specifically PhilHealth, to pay its obligations to hospitals in the city, especially the private ones.

He said that the unpaid PhilHealth dues are providing “financial burden” to some private hospitals amid the pandemic.

In the same statement, Philhealth clarified though that not all claims will be paid.

“Hospitals are aware that not all claims filed to PhilHealth will be paid. There are those which are returned to the hospital/facility, and some are denied,” it said.

PhilHealth-7 explained that Return to Hospital (RTH) claims are deficient claims after due adjudication and validation, redirected back to the hospital/facility with instructions to comply with certain requirements, but from which the action of returning the complied claim to PhilHealth may result in the reversal of the deficiency into a good claim or non- compliance that may result into the denial of the claim.

A denied claim, on the other hand, 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 RTH or due to a finding of an unmet requirement.

Per the statement, in 2018, PhilHealth introduced the Reconciliation Summary Module (RSM) in its Health Care Institution Portal to provide accredited hospitals and facilities with updates on the status of claim reimbursements.

The RSM aims to provide hospitals with complete and timely information on the progress of their claims submitted to the state health insurer, particularly on claims received, in process, already paid, or denied.

They can also cross-reference their claims data against PhilHealth records with precision, eliminating inaccuracies caused by errors such as double-entries, and the users can also check if a claim is due to be returned and the possible remedies to ensure reimbursement.

“In the past three weeks, the Benefits Administration Section of PhilHealth Region-7 has been conducting virtual orientations with accredited health care facilities and hospitals in Central Visayas to address their concerns. Hospitals have been encouraged and instructed to check on their claims that remain unpaid beyond 60 days from the date of submission,” the statement further read.

Section 35 of the Implementing Rules and Regulations of the National Health Insurance Act (Republic Act 7875, as amended by RA 9241 and RA 10606, states that all claims for reimbursement or payment for services rendered shall be filed within a period of 60 calendar days from the date of discharge of the patient from the health care provider.

Section 23 of the same amended law requires PhilHealth to process, review and pay the claims of providers within a period not exceeding 60 days as well. — KQD (FREEMAN)