MANILA, Philippines — Marikina Rep. Stella Quimbo questioned on Friday the “mechanical” reasons given by the Philippine Health Insurance Corporation (PhilHealth) for the denial of hospital claims and claims that age beyond 60 days.
During the hearing of the House Committee on Good Government and Public Accountability, Dr. Jonathan Ele the head of PhilHealth’s program management team for claims bared the common reasons for claims that age beyond 60 days:
– No value has been set for the patient priority subgroup
– No value has been set up for services covered in the COVID testing claim
– Without attached valid itemized billing
– No value has been set for the flag indicating whether test kits have been donated or not
– Without attached valid case investigation form- Without attached valid SARS-COV-2 claim summary form
– Required document is unavailable/incomplete/inconsistent/unreadable
– Filed beyond 120-day statutory period
– No applicable entry found in the benefits library
– Double filing/same day confinement
Under PhilHealth’s Charter, all claims must be processed within 60 days.
Quimbo, however, noted that there seems to be no valid reason why the claims should age beyond two months.
“Nakasulat (It says here that there is) no value, so it’s just a figure, a value that you need to indicate, hindi na ‘yan (these are not) documents,” she said.
“How about itong no value has been set for whether testing kits have been donated or not? So again, it’s just a tick box, you just have to indicate if it is donated or not… My point being, looking at all these reasons, there seems to be no reason kung bakit dapat siya magtagal ng beyond two months,” stressed Quimbo.
PhilHealth’s reasons for denial of claims, said the lawmaker, are likewise too “mechanical.”
“Looking at the reasons for denial they are also very mechanical. Walang anything that says we suspect the claim to be fraudulent? Isn’t that an important reason for possible denial?” she asked Ele.
Ele noted that among the reasons for claims ageing beyond 60 days are double filing or same-day confinement.
“So it’s an indication of fraud?” asked Quimbo.
“There is a possibility na pwede pong hindi, there is a possibility of fraud po (There is a possibility that it is fraud. There is a possibility that it is not),” Ele answered.
According to Ele, PhilHealth has received a total of P170.2 billion worth of claims from January 2022 to August 24, 2021. Of this, P132 billion have been paid, P21.1 billion are in process, P10.4 billion worth of claims have been returned to hospitals, and P6.2 billion have been denied.