Philhealth R12 Addresses Issues on COVID-19 Claims

Koronadal City, South Cotabato – The Philippine Health Insurance Corporation (PhilHealth) Region XII Office, represented by its acting Regional Vice President Dr. Hector Leonardo P. Malate, MD, formally addressed the issues and concerns related to COVID-19 claims in the SOCCSKSARGEN region on November 10, 2020 at the Provincial Capitol of South Cotabato.

Malate stated that they have strengthened the review of COVID-19 claims by ensuring that all COVID-related claims have to go through the Medical Pre-Payment Review, where they are being evaluated together with the Clinical Chart.

As a newly appointed Philhealth official in the region, Malate said that since he assumed position, he has been focusing on two (2) priorities. The first is the resolution of legal cases in the region, and the second is the Claims Processing, specifically the COVID-19 claims.

“Bukod dun sa membership and collection program ng Philhealth na kailangan talagang tutukan, I’d like to focus on two (2) activities that I would like to prioritize. Number one is yung resolution ng ating legal cases sa ating region because medyo marami po tayong cases na backlog. Siguro nasa mahigit tatlong libo yung para sa fact-finding investigation report at mahigit sampung libo ang ating mga claims na nasa Claims Review Committee. Ito yung ating mga denied claims na kailangang i-deliberate at i-reconsider na babayaran po ng Philhealth,” he said at the provincial government’s press conference, Kapihan sa Kapitolyo.

“Another one na gusto kong tutukan is yung ating Claims Processing, specifically yung ating COVID-19 claims. Recently I’ve issued a memorandum addressed to all healthcare providers na yung magke-claim ng COVID-19 claims at benefits at dapat dumaan muna sa tinatawag nating Medical Pre-payment Review. Lahat ng mga hospital na nagsa-submit po ng mga claims ay kailangan din mag submit ng certified true copy ng clinical charge because sa region, we want to be careful in paying our case rate, especially our COVID-19 claims, kasi napakali ng ating benefit packages. Gusto natin na maingat tayo sa pagbayad at sigurado tayo na tama ang kine-claim at binabayaran natin sa mga hospitals,” he added.

“We are very careful in paying the COVID benefits. Lahat ng COVID claims dumadaan sa Medical Pre-payment Review, so yung doktor po natin na nasa Benefits Administration Section, their claims are being evaluated together with the clinical chart. So kung sa tingin nila ay hindi ito COVID claim, dapat klaro at tama ang kine-claim ng ospital. So dadaan po yun sa medical evalutaion. If it is COVID, we will pay the package, whether moderate, severe, or critical pnuemonia. Merong right ang Philhealth to pay or deny the claim. So kung sa tingin namin ay hindi naman talaga sya COVID, we might deny the claim, or pay it based on the regular case rates. Yung totoong COVID claims naman, babayaran namin dun sa COVID benefit packages,” he also expressed.

Regarding the process of filing the complaints, it is the regional office that conducts the fact-finding investigation reports, which will then be submitted to the Philhealth Central Office that will determine the appropriate administrative case to be filed.

For the criminal cases, on the other hand, the regional office coordinates with the National Bureau of Investigation (NBI), the agency that requires doctors and/or hospitals to submit corresponding documents for proper investigation.

He also said that they currently have a backlog of over 3,000 cases for submission to the fact-finding investigation and around 10,000 cases involving claims that are pending with their review committee.

“We’re still waiting kung ano ang kanilang magiging aksyon dun sa finorward namin na hinihinging dokumento, especially with regard dun sa hinihinging dokumento ng COA [Comission on Audit]. As of this time, wala pa naman kaming natanggap na recommendation kung meron bang kaso o wala. But anyway, whatever are the findings of our government agencies, we will cooperate as officers, as public servants ng Philhealth. Hindi naman po nawawala yung mga issues na claim or allegedly hindi nababayaran ng Philhealth yung hospital. Meron po tayong ginagawa para ma-address ito.  We reconcile the records of the hospital and of Philhealth. Magsa-submit po ng listahan ang hospital at titingnan po natin sa ating database kung bayad o hindi,” he finally stated.