PhilHealth urges hospitals with claims due to late change on COVID-19 coverage to seek arbitration

PhilHealth chief Dante Gierran. INQUIRER.net file photo / CATHY MIRANDA

MANILA, Philippines — The Philippine Health Insurance Corporation (PhilHealth) has urged healthcare institutions that may contest the denied claims brought by a late circular on the state insurer’s updated coverage for COVID-19 cases to seek arbitration instead.

PhilHealth president and chief executive officer Dante Gierran made this suggestion on Tuesday, as he was asked by members of the House of Representatives committee on health about how the corporation would correct possible problems stemming from the PhilHealth Circular 2021-08.

Gierran said that the possibility of appealing through PhilHealth’s arbitration panel is always open — angering lawmakers.

“This honorable committee had heard a lot, there was an admission, by no less than our Assistant […] there was some kind of delay that was made by the corporation.  And actually, this was already discussed between among us, and we have the option to let the hospitals make their appeals to the arbitration sector of the corporation,” Gierran told the House panel.

PC 2021-08 dated last June 17, 2021, removed COVID-19 probable cases from the in-patient package, due to supposed abuse as some patients got higher compensation despite them not contracting COVID-19.

However, the problem is that the circular carries a retroactive effect, which means COVID-19 probable cases whose PhilHealth payments have been accepted by hospitals starting November 26, 2020, would also be affected.  In return, PhilHealth would no longer allow hospitals to make claims based on these conditions.

Lawmakers have strongly objected to these suggestions from Gierran, urging PhilHealth to reconsider its policy as patients who have benefitted from this scheme can no longer be pursued by the hospital, which meant that it would be hospitals or healthcare facilities who would shoulder the bill.

“‘Yong retroactivity, they think, or they thought is favorable to the interests of PhilHealth.  But what about the interest of the Filipino people, particularly our partners, the hospitals?” House committee on health chairperson and Quezon 4th District Rep. Helen Tan asked.

“Kasi definitely ito, nagamit ng ating mga pasyente, na-confine, and inapply anumang diagnosis and appropriate benefit package […] Wala na ‘yong pasyente, nagamit na niya ‘yong PhilHealth benefit, ang magsu-suffer is the hospital who incur ‘yong mga expenses like medicine, supplies, doctors, lahat-lahat ng ginamit,” she added.

(Because definitely, these allocations were already used by our patients who were confined, provided diagnosis, and given the appropriate benefits package […] But now the patient is no longer there, they have used the PhilHealth benefit, and hospital who incurred the expenses like medicine, supplies, doctors, and all the things are left to suffer.)

Tan also pointed out that it is not the fault of hospitals as to why the circular was crafted late — around seven months from which the retroactive effect takes place.

Earlier, also during the House committee hearing, PhilHealth Acting Executive Vice President Eli Dino Santos admitted responsibility for the late circular.

READ: PhilHealth admits fault on changing coverage over COVID-19 probable cases 

Hence, the burden should not be passed on to the public or to the hospitals and facilities that are already burdened due to the COVID-19 pandemic.

“Kung ang sinasabi ni president, Atty. Gierran, is hospital ang mag-aappeal, bakit hospital ang mag-appeal wherein you can provide remedy through amending your circular or resolution?” she asked.

(If what PhilHealth president Atty. Gierran said is that hospitals would make an appeal, why would they make an appeal wherein you can wherein you can provide remedy through amending your circular or resolution?)

“There is an admission of inefficiencies doon within the PhilHealth, so siguro mali po na itulak sa ating healthcare providers ‘yong burden na currently naman ay nakikita ano ang burden na dinadala nila just to accommodate our patients, whether COVID or non-COVID, talagang hirap na hirap na sila,” she added.

(There is an admission of inefficiencies within the PhilHealth, so maybe it is wrong to push the burden to our healthcare providers which are currently, as we have seen, have been burdened just to accommodate our patients, whether COVID or non-COVID, they are really struggling.)

Gierran eventually conceded, saying that he would bring up the issue to PhilHealth’s Board of Directors, as it is the body that is above the managerial officials.

He also implied that PhilHealth’s response was slower as they had to restructure the organization upon orders from President Rodrigo Duterte to rid the insurer of corrupt officials.

“(In the) management I am the highest because I am the PCO, but Madam Chair, somebody, or a body, there is body that is higher than I am, and so coming from the insinuations that this honorable committee has made, I would refer this — there’s no other way for me to do — I would refer this to the authority that is higher than I am, which is the board,” he added.

JPV