The Philippine Health Insurance Corporation (PhilHealth) admitted on Thursday the delays in the processing of claims for COVID-19 cases, amid a grievance from a hospital group regarding unpaid claims amounting to billions of pesos.
PhilHealth spokesperson Shirley Domingo, in an interview with Unang Balita, said the pandemic has also affected the agency’s workforce.
“There is really a delay in the processing of claims because even PhilHealth was affected by the pandemic,” she said, adding that some of their employees needed to be confined or put in isolation following exposure to COVID-19.
This developed as the Philippine Hospital Association (PHA) on Thursday criticized PhilHealth’s slow release of payments to medical facilities with COVID-19 claims that are not made under the debit-credit payment method (DCPM).
The DCPM was created last month after President Rodrigo Duterte ordered PhilHealth to expedite the reimbursement of hospital claims in high and critical risk areas as COVID-19 cases surged.
Under the DCPM, hospitals need to apply and sign an undertaking stating that healthcare facilities will receive 60 percent of the total amount of receivables subject to 2 percent expanded withholding tax.
PHA president Dr. Jaime Almora, however, said the undertakings “have provisions that are not clear to medical facilities.”
At a Senate hearing on Wednesday, Almora said private and public hospitals were forced to use their savings and borrow from in order to sustain operations due to PhilHealth’s alleged failed to pay the claims for COVID-19 cases since March 2020.
Domingo, however, said PhilHealth shelled out P4.84 billion in 2020 for “COVID-related expenses,” including payment to hospitals. For 2021, PhilHealth has already spent P4.88 billion as of May 17.
She said the processing of claims is not simple and cannot be rushed.
“All claims undergo a process before payment. There are claims form that have to be assessed by doctors and claim processors,” said Domingo.
But Almora, in an interview with ABS-CBN’s Teleradyo, said: “It’s like the IRM (interim-reimbursement mechanism), the release of payment is fast but the processing of claims not made under the debit-credit payment method is slow. Many are denied and returned to the hospital. Non-COVID claims are paid.”
“Hospitals were surprised because we only expected that payment would be expedited, why do we have to apply and sign an undertaking? There are provisions not clear to them,” he said.
Almora said PhilHealth should give hospitals more time to explain their side.
“Summon hospitals and show them the problems so it can be settled. Give them a chance to explain their side. That’s the lacking part: reconciling and giving time to hospitals to explain,” he said. “It’s done in some areas but by large it’s the lacking approach.”
Under the DPCM, Domingo explained that PhilHealth would pay 60% first while the processing is ongoing, then the remaining 40%, minus withholding tax and other deductibles, will be released after processing and reconciling are completed.
Domingo also assured the public that PhilHealth, which has been the center of corruption investigations involving former officials in the past, has funds to cover its obligations.
PhilHealth owes private hospitals more than P28 billion, according to the assessment of the Private Hospitals Association Philippines Inc. (PHAPI) in May.
PhilHealth also pays only 35 percent instead of 60 percent of their claims under the DCPM, PHAPI President Jose Rene de Grano said earlier.
The state insurer has released some P6 billion to 182 hospitals who have availed of the DCPM, said Domingo, also PhilHealth vice president for corporate affairs.
Claims not made under the DCPM undergoes regular assessment, Domingo said. These are reconciled by regional PhilHealth offices with the hospitals, she added.