PhilHealth temporarily shelves circular suspending payment of hospital claims

MANILA, Philippines — The state-owned Philippine Health Insurance Corp. (PhilHealth) has put on hold a controversial circular suspending the payment of suspicious hospital claims and promised to look for better solutions to fight health insurance fraud.

In a phone interview on Sunday, PhilHealth spokesperson Dr. Shirley Domingo said they would issue an advisory to healthcare providers on the suspension of Circular No. 2021-0013, or the temporary suspension of payment claims (TSPC), but she said the insurer would also continue engaging them in a dialogue to further explain the circular.

“[But] we still need to have a program [against] insurance fraud. It’s a reality. We’re not saying all hospitals [engage in fraud], it’s not like that,” Domingo said.

She said the temporary suspension came after PhilHealth’s discussion with the Department of Health and after taking into consideration the issues raised by the healthcare providers.

Saying they were pushed to the wall, hospitals earlier threatened to disengage with PhilHealth by not renewing their accreditation next year should the agency push ahead and enforce its controversial circular.

Dr. Jaime Almora, president of the Philippine Hospitals Association, on Sunday said PhilHealth should not have issued the directive in the first place since there were already mechanisms in place to investigate fraudulent activities.

The difference this time, he said, was that PhilHealth was allowed to stop the payment of all COVID claims or all claims for that matter of an entire hospital over one suspicious case.

Hospital officials also said they were given little time to respond to PhilHealth’s investigation, while the suspension of reimbursements could last up to eight months.

Varying claims

Dr. Jose de Grano, president of the Private Hospitals Association of the Philippines, said they would await the advisory before giving its comment, while Almora said hospital members would have to discuss again whether or not to stay under PhilHealth.

The majority of about 2,000 public and private hospitals are accredited by PhilHealth.

“[The TSPC] was just their excuse to not pay their debt,” Almora said earlier.

Hospitals claimed that PhilHealth owed them P86 billion, mostly in COVID claims, from January 2020 to June 2021, although this amount included those already denied by PhilHealth or returned to hospitals for further documentary compliance.

PhilHealth said there was only P12.9 billion worth of hospital claims being processed as of June 30.

Domingo said the amount kept changing. On average, she said PhilHealth received 50,000 hospital claims daily and disbursed P2 billion to hospitals weekly.

The TSPC was the subject of a series of congressional inquiries over the past two weeks.

In July, the National Bureau of Investigation sued officials from PhilHealth and a private hospital in Cebu City for collusion and upcasing a non-COVID patient to a severe illness to get a bigger benefit.