PhilHealth, hospitals clear unpaid claims

PATIENTS of private health care institutions in Central Visayas are assured of continued PhilHealth benefits as hospitals are working on the renewal of their accreditation with the insurance body.

The move came after the Private Hospitals Association of the Philippines Inc. (Phapi) reiterated its call to sit down with the Philippine Health Insurance Corporation or PhilHealth for the latter to “immediately” settle unpaid claims.

Phapi president Dr. Rustico Jimenez, in a Nov. 25, 2019 advisory to Phapi members, informed them that Phapi would notify PhilHealth of the intention of its 733 member-hospitals, representing 44,700-plus beds nationwide, “to hold back or hold in abeyance” their accreditation for next year unless PhilHealth agrees on their set of “talking points,” including that at least 80 percent of pending claims of each hospital be paid on or before Dec. 20, 2019.

The state health insurer reportedly owes P4 billion to some 125 private hospitals.

Dina Cinchez, PhilHealth Central Visayas information officer, said 25 of 30 private health care institutions in the region met with PhilHealth on Wednesday, Dec. 18, to clarify issues on unpaid claims and to begin processing their accreditation.

Cinchez said that among those who have already started processing the renewal of their accreditation with PhilHealth is the Visayas Community Medical Center (VCMC).

According to VCMC finance officer Rey Javier, their concern is on the Department of Health’s issuance of the license to operate (LTO), which is one of the supporting documents needed in their application for the renewal of accreditation.

Aside from VCMC, the Adventist Hospital Cebu, through its patient business director Julian Cefriano, also expressed support to PhilHealth.

PhilHealth 7 regional vice president Lourdes Diocson, for her part, assured that it will raise their concerns to their central office, especially on the extension of the deadline for re-accreditation in consideration of the LTO issuance.

During their meeting Wednesday, PhilHealth informed the hospitals of the claims received by the corporation from 2017 to 2019 with details on number of returned-to-hospital (RTH) claims, denied and paid claims, as well as claims currently being processed.

It added that among the factors that lead to RTH claims are incomplete or unreadable Claim Form 4 (CF4) entries, which provide the summary of pertinent clinical information of a patient/member during their hospitalization that shall be utilized by PhilHealth to conduct evaluation and review of claims.

Another factor identified was technical errors encountered in submitting the CF4 through eClaims, an electronic system of submission and processing of claims.

PhilHealth had prescribed a medical prepayment review and required the use of the CF4 for all admissions since March 1, 2019.

Diocson assured the hospitals that PhilHealth is doing “extra effort” for the reconciliatory process of their pending claims and implementing solutions to problems observed in the PhilHealth’s shift to eClaims.

“PhilHealth’s information technology management department has seen that one of the main causes of the problem is storage. We are hoping that the Electronic Claims Cloud Storage would be a very good solution to this,” she added. (WBS)