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The Philippine Health Insurance Corporation (PhilHealth) processes members’ transactions at PhilHealth National Capital Region Central Branch in Quezon City. Maria Tan, ABS-CBN News/File

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Lawmaker urges PhilHealth to revise claims processing amid billions in denied, return to hospital claims

Paige Javier

ABS-CBN News

MANILA (UPDATE) –  Marikina 2nd District Rep. Stella Quimbo urged the Philippine Health Insurance Corporation (PhilHealth) to revise its policies and requirements in claims processing to reduce the number of denied and return-to-hospital (RTH) claims. PhilHealth Senior Vice President for Fund Management Sector Renato Limsiaco Jr. said that in 2024, PhilHealth had denied 483,000 claims amounting to P4.7 billion. From 2018 to 2023, PhilHealth denied 3,017,819 claims amounting to P32.4 billion. Meanwhile RTH claims reached 304,082 in 2024 amounting to P4.2 billion. From 2018 to 2023, PhilHealth had 1,739,000 RTH claims amounting to P18.3 billion.<div><a href="https://www.abs-cbn.com/video/business/01/12/22/philhealth-eyes-payment-of-p25b-hospital-claims-in-next-6-months" rel="noopener noreferrer" target="_blank">PhilHealth eyes payment of P25 billion pending hospital claims in next 6 months </a></div>Quimbo said the strict processing of claims may have a negative effect on healthcare access as it affects the cash flow of hospitals, some of which may be forced to close down. The Marikina lawmaker urged PhilHealth to immediately address the issue and minimize denied and RTH claims.&quot;Ang nangyayari po, iniipit natin yung liquidity ng mga ospital, at in the end po, napipilitan magsara. Yun ang practical effect sa tao,&quot; Quimbo added. PhilHealth also admitted during the hearing that it still has P21 billion worth of payables to hospitals.According to Health Assistant Secretary Albert Domingo, most of the denied claims are due to them being filed after the 60-day deadline in the law, which they are now looking to revise. Limsiaco meanwhile said PhilHealth initiated a claims reconciliation system last year, after approval of the board and Health Secretary Teodoro Herbosa.  <div>BECAUSE COA IS STRICT?</div>PhilHealth President and CEO Emmanuel Ledesma Jr. meanwhile said RTH claims make up only 2 percent of claims handled by the state-led health insurer, while denied ones were 4 percent of the total. He said strict guidelines set by the Commission on Audit constrain PhilHealth from loosening its standards.&quot;There will come a time that we will be answerable to COA. We are very very concerned with all of their findings and their negative comments. So maingat po kami diyan,&quot; Ledesma said.Quimbo however did not accept this and said that there are ways to work and engage with COA. In its 2023 annual audit report, COA flagged P1.3 billion worth of denied and returned reimbursement claims to hospitals from PhilHealth.COA urges DOH to resolve P1.3 billion worth of hospital claims denied, returned by PhilHealth <div>BILL ON HOSPITAL AMNESTY </div>AGRI Party-list Rep. Wilbert Lee said he will file a bill seeking amnesty for blacklisted hospitals over double and denied claims.The congressman said most of the cases happened after 2018 when PhilHealth digitalized its system, wherein there were multiple entries. He said that instead of blacklisting these hospitals, PhilHealth should just ask them to return the money from the alleged double payment. &quot;Kailangan natin silang tulungan kasi ang effect nito, dahil sa napakaraming denied claims, hindi na po nila tinatanggap lahat ng PhilHealth patients. Pinipili nalang po,&quot; he added.<div>OUTSOURCE CASE RATE REVIEW</div>Lawmakers also suggested that PhilHealth hire a private health insurance firm to speed its review of case rates following the increase in most of it benefit packages this year.AGRI Party-list Rep. Wilbert Lee questioned anew what he called the slow adjustments of case rates by the state-run health insurer.PhilHealth announced an increase in almost all of its benefit packages by 50 percent this year. The hike covers 9,000 case rate packages for its members. It will be providing coverage for emergency outpatient services and preventive oral health services, which were previously excluded from existing benefit packages.The state-run health insurer will release new benefit packages for prescription glasses for children 0 to 15 years old, rehabilitation services and assistive mobility devices. PhilHealth will also expand the benefit packages for various kinds of cancer.In a previous House hearing, Ledesma said PhilHealth has a surplus of P150 billion, a total reserve of P200 billion and an investment fund worth nearly P489 billion. The state-run health insurer also expects P203 billion collection for direct premium contribution, an increase from the P178.5 billion collected in 2024. PhilHealth has allotted P271 billion for benefit expansion for this year.

PhilHealth denied 483,000 claims from 2018 to 2023 amounting to P4.7 billion.

PhilHealth denied 483,000 claims from 2018 to 2023 amounting to P4.7 billion.

Solon urges PhilHealth to revise claims processing amid billions in denied, return-to-hospital claims

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Solon urges PhilHealth to revise claims processing amid billions in denied, return-to-hospital claims

Paige Javier,

ABS-CBN News

Published Jan 15, 2025 04:46 PM PHT

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Updated Jan 15, 2025 06:03 PM PHT

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