PhilHealth execs in Iloilo told to explain delays

MANILA, Philippines — The Anti-Red Tape Authority (ARTA) ordered two officials of the Philippine Health Insurance Corp. (PhilHealth) to explain the delays in the payment of claims amounting to over P690 million to seven hospitals in Iloilo City.

In a statement, the ARTA said it issued on Tuesday a show cause order against Alfredo Pineda II, PhilHealth vice president for Area III, and Valerie Anne Hollero, regional director for Office VI.

PhilHealth owes over P690 million to the Iloilo Mission Hospital, St. Paul’s Hospital of Iloilo, Iloilo Doctors’ Hospital, Medicus Medical Center, The Medical City of Iloilo, Qualimed Hospital Iloilo, and the Metro Iloilo Hospital and Medical Center Inc.

The state health insurer failed to pay the hospital on the due date, which was last month, ARTA said.

The officials were given seven working days from the receipt of the order to explain the delay.

Should the officials’ response to the show cause order be found insufficient, ARTA said charges may be filed against them for violation of Republic Act 11032 or the Ease of Doing Business and Efficient Government Service Delivery Act of 2018.

“We want them to explain why they have not yet paid the hospitals. Considering it’s been a long time, they should have already been paid. They should just pay and do a very efficient post audit afterwards,” ARTA director general Jeremiah Belgica said.

“For whatever policy or actuarial reason, the hospitals should not be made to suffer because all of their sufferings ultimately redound to the disadvantage of the people they served,” Belgica added.

He reminded PhilHealth offices to comply with the 60-day period in processing hospital claims as stated in their special law.

He urged other hospitals facing similar issues to get in touch with ARTA.

Among the issues ARTA found in PhilHealth’s processing of payment for hospital claims is the tedious review of applications as some display wrong diagnoses and faulty documentation.

To address this, ARTA recommended having a streamlined pre-assessment or pre-payment review of documentary materials, post-evaluation audit and automation.

In September, the IATF approved a recommendation of the ARTA and PhilHealth to lift the limitations on the coverage of the debit-credit payment method (DCPM).

The move gave the state insurer flexibility in applying the DCPM coverage to allow faster release of payment for COVID claims of both public and private hospitals.

Earlier, the DCPM was only available to high and critical risk areas based on the two-week growth rate, average daily attack rate and health care utilization.

To help PhilHealth address issues in the payment of hospital claims, ARTA formed a support group composed of officials from the Department of Information and Communications Technology, Office of the Presidential Adviser on Streamlining of Government Processes, Department of Health, Food and Drug Administration and Health Technology Assessment Council.

As this developed, PhilHealth said it is planning to settle the P20 million reimbursement claims of private hospitals by December.

Speaking at the Laging Handa public briefing yesterday, PhilHealth corporate communications senior manager Rey Baleña said efforts are underway to release the payment for the claims of private hospitals at the soonest possible time.

“It won’t take any longer as everything has been mobilized,” Baleña said when asked if the reimbursement claims can be paid within the month or by December.

He said the claims should be settled before December since PhilHealth is exerting all efforts to release the payment soonest.

PhilHealth has been in constant dialogue with the Private Hospitals Association of the Philippines Inc. (PHAPI) to prevent the planned disengagement by some of their members due to failure to pay reimbursement claims, Baleña said.

At this time, Baleña said, they have not received any notice from private hospitals of their intention to disengage from PhilHealth.

The state health insurer, he said, has sufficient funds to pay for the claims, but the pandemic affected the operations of PhilHealth and caused delays in the processing of claims.

Aside from the pandemic, questionable claims and lack of supporting documents caused the delay as PhilHealth needs to return the papers to the hospitals for completion, which account for seven percent of total claims.

It takes an average of 42 days to process and pay the claims, and PhilHealth is mandated to complete it within 60 days.

From January 2020 to October 2021, Baleña said, PhilHealth paid its partner hospitals some P152.8 billion, comprising 75 percent of total claims. – Mayen Jaymalin