PhilHealth warns hospitals against turning away members

MANILA, Philippines — The Philippine Health Insurance Corp. (PhilHealth) warned on Monday an organization of private hospitals against refusing to honor benefits accorded to its members.

PhilHealth President Alex Padilla reminded Dr. Rustico Jimenez, head of the Private Hospitals Association of the Philippines Inc. (PHAPI), that doing so would be against the law and run counter to the group’s “commitment to PhilHealth.”

“All PhilHealth members must be given the full benefits that they are entitled to—no more, no less,” he said in a press conference in Malacañang. “It has to be the full benefits. Hospitals can’t play with them.”

Jimenez earlier claimed that PhilHealth had not been settling claims by accredited hospitals on time. As a result, he warned that PHAPI hospitals would charge the full amount of hospitalization for PhilHealth members.

“There is no truth to the allegations of Dr. Rustico Jimenez that due to mismanagement, PhilHealth owes P600 million to 600 private hospitals,” Padilla said.

Padilla insisted that PhilHealth had not been remiss in its responsibility to settle claims in 10 hospitals earlier mentioned by Jimenez. He also questioned why a certain “De Vera Hospital” in Bulacan was included in Jimenez’s list, saying there was no such medical facility in Central Luzon.

Padilla said the agency has been investigating some 8,000 cases of allegedly fraudulent claims “of varying degrees.” These cases include the use of “fictitious patients,” he said.

As of this month, he said PhilHealth denied a total of 37,358 claims worth P386 million. He said the agency also returned 152,782 claims worth P1.58 billion to hospitals that had made the requests.

But Padilla made it clear that such cases were not necessarily fraudulent.

Per PhilHealth policy, incomplete claims or those filed after the required 60-day period were either “returned to the hospital or denied,” he said.

PhilHealth would usually process “good” claims — or those with complete documents and filed within the prescribed period — in 60 days, he said.

PhilHealth now covers 14.7 million “poor and near poor” families compared to the 5.2 families enrolled last year, according to Padilla.