Wishy-washy PhilHealth policies

CTALK - Cito Beltran - The Philippine Star

While hospitals in the NCR have been given much attention and compensation by PhilHealth, it seems that private hospitals outside the NCR Plus bubble continue to struggle to survive, partially due to the inability of the national health insurer to act and pay out claims of provincial private hospitals. Yes, PHIC paid billions to hospitals but those were apparently mostly in Metro Manila. According to one source, “While PHIC is busy sorting out its problems and looking for real solutions to this problem of UNPAID CLAIMS, the private hospitals nationwide continue to suffer. Our savings have already been depleted due to substantial drops in revenues in 2020 worsened by PHIC’s inability to pay our claims (now in the billions of pesos). Many hospitals have resorted to borrowing funds from banks and third parties, which has only put them in a more pitiful solution.”

Aside from lost revenues and financial woes, a number of hospitals have been forced to undertake cost cutting measures, primarily by reducing employees down to bare essentials. The number of nurses have been reduced while working hours have been extended, many administrative personnel have lost jobs or forced to reduce work days or pay and I’ve also learned of some hospitals quietly being sold to big corporations because the original incorporators or owners can no longer sustain their operations.

A hospital administrator I spoke with pointed out that part of the problem is the wishy-washy policies and changes that PhilHealth has been doing from 2020 to 2021. In their 2020-0011 memo, for instance, PhilHealth announced full financial coverage for HCWs or health care workers and patients against COVID-19. As COVID-19 cases started piling up, PhilHealth balked at the claims and costs and announced that health care workers were no longer 100 percent covered and would be covered based on a specific case rate or fixed coverage. Then in May 2021 PhilHealth announced through advisory #0011 that “the PHIC is currently reviewing its policies and benefit packages. Meanwhile in the interim, the said circular 2020-0011 shall remain in full force and effect and PHIC shall continue to provide full financial risk protection among public and private HCW who have contracted COVID-19 until further notice.”

While it was so easy for PhilHealth to temporarily correct the situation, so many patients and claims fell through the cracks in between announcements.

A couple of people I know had to raise hell in the respective hospitals where their family members were confined because the patients who had severe COVID were being downgraded to moderate COVID. Family members were under the impression that PhilHealth would pay for everything based on the “No Balance” propaganda of the PHIC. But because PhilHealth would only pay based on COVID case rates, the hospitals needed to find some way of charging the balance to the patients or end up losing money with every COVID patient that entered the hospitals.

Aside from the wishy-washy policies for health care workers, another problem involves many suspected COVID-19 patients who manifested symptoms and were classified as COVID positive but eventually tested negative. With very little known about the disease last year especially in the provinces, the protocol was to treat all suspected cases as COVID positive. Remember that in 2020 there were very few laboratories, the fear factor and protocols were extreme and figuring out the difference between the flu, pneumonia and COVID-19 was a fine slice. So hospitals treated everyone the same – isolation, oxygen, x-rays, fluids, HCWs wore PPEs, etc. but when the hospitals filed their claims, the PHIC said sometime in March 2021 they would only approve claims for RT-PCR positive cases.

So what happens to all the expense and work that went into addressing the RT-PCR negative tests? At best they all fall under “simple pneumonia” that does not require testing, PPEs, isolations, etc. and as a result, hospitals which attended to these patients only get back part of their costs and definitely no profits or mark ups.

A veteran physician also told me about the “Take or Pray” approach of PhilHealth, referring to the situation that many provincial private hospitals allegedly find themselves in. It seems that the national health insurer’s style or remedy to COVID-related claims is to offer 60 percent payment of claims in order to avoid prolonged verification, investigations and red tape in the processing of payments for claims made by private hospitals. Those who refuse are free to do so but their next option is to pray for a miracle that they eventually get paid the full amount they hoped to collect on.

Our source believes or assumes that it is a formula intended to simply slice off any excess claims or possible fraud in the submissions and reduce PhilHealth’s pay out to private hospitals. But for hospitals that submitted legitimate claims, the 60 percent payout scheme would be tantamount to admitting their claims are fraudulent, as well as the fact that it may encourage PhilHealth officials to undercut and underpay legitimate claims. While most hospitals refused to agree to the “solution,” one hospital owner who decided to bite the bullet reportedly now regrets doing so because his hospital did not automatically get the full 60 percent of claims but instead ended up with partial payments.

To be fair to the PhilHealth, none of our sources accused its officials of corruption, wishy-washy definitely, using delaying tactics – obviously, internally conflicted – yes, and overly sensitive to politicians – absolutely. But no one ever mentioned corruption. We have invited the new set of officials of PhilHealth to come to guest on our program AGENDA but they remain apologetic in their refusal to speak to us. Perhaps it is truly difficult to address an issue that you really have no real solution for.

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E-mail: utalk2ctalk@gmail.com

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