Amid reports that several hospitals are preparing to disengage beginning this month from the Philippine Health Insurance Corp., Malacañang has again urged the state health insurer to settle the reimbursement claims of the hospital operators. Government officials have repeatedly given assurance that PhilHealth has sufficient funds to cover all claims.
So why does the Private Hospitals Association of the Philippines Inc. continue to lament the non-payment of the claims of most of its members? PHAPI, with about 700 members nationwide, estimated that PhilHealth had unsettled claims amounting to P86.1 billion from January 2020 to June this year.
PhilHealth, on the other hand, said the unsettled claims amounted to only P12.9 billion as of June 30. Claims amounting to about P9 billion were returned to the hospitals because of documentary deficiencies, while other claims totaling P6 billion were denied, according to PhilHealth.
The state insurer suspends the payment of claims that it suspects to be fraudulent. Since 2019, such suspensions have covered more than 20 health centers, dialysis and maternity clinics as well as doctors. Twenty possible sources of fraudulent claims, however, should not derail the operations of the majority, especially in the middle of a deadly pandemic.
For the public, what “disengagement” from PhilHealth means is that patients will have to pay out of their own pocket for services in these hospitals.
PhilHealth has explained that it wants to put an end to fraudulent claims filed by health facilities and physicians. Last year President Duterte appointed a retired head of the National Bureau of Investigation, Dante Gierran, as PhilHealth president and chief executive officer, with the mission of cleaning up the settlement of claims. Gierran, a lawyer and accountant, has followed the President’s instruction.
In this pandemic, however, hospitals play a critical role in the response. As PHAPI members have pointed out, they need liquidity for their operations, including for the recruitment of more healthcare workers. If there are fraudulent claims, the majority must not suffer, compromising the quality of the services they provide to the public.
Malacañang has been telling PhilHealth, which is an attached agency of the Department of Health, to reimburse the hospitals. Why this isn’t happening – as hospital operators are lamenting – is a sad reflection of the quality of the pandemic response.