MARIKINA CONGRESSWOMAN Stella Quimbo filed a resolution seeking a congressional inquiry into the unpaid benefit claims of the Philippine Health Insurance Corp. (PhilHealth) to health care facilities (HCFs).
Quimbo on Monday filed House Resolution 1769, which directs the House Committee on Good Government and Public Accountability to also look into the benefits claims processing systems of PhilHealth, and the effectiveness of the Debit-Credit Payment Method (DPCM) policy as a mechanism to address unsettled claims. A copy of the bill was sent to the media on Tuesday.
Quimbo said the financial difficulties resulting from the unpaid claims have made it difficult for private hospitals to comply with the Department of Health (DOH) directive to expand capacity amid the surge in coronavirus disease (Covid-19) cases in the country.
“There is an urgent need to settle payments due to hospitals so as not to further hinder our health system’s capacity to respond to the ongoing pandemic,” she said.
Private Hospitals Association of the Philippines (PHAPi) president Dr. Jose de Grano said the value of PhilHealth’s unsettled claims has ballooned to P28 billion across 700 private hospitals, which only covers March to December 2020.
Meanwhile, another resolution, filed by Quimbo, calls for a congressional inquiry on the status of the National Health Insurance Program administered by the PhilHealth, particularly the fund management and utilization in light of the inefficiencies and anomalies revealed in previous probes last year.
It was revealed in the past congressional hearings that PhilHealth’s benefit payments have been recorded as 22 percent overpayment and 78 percent underpayment due to inaccurate case rates, where overpayment results in excessive payments to health care institutions, while underpayment forces patients to cover costs out-of-pocket.
The House committees also discovered abuses in the Interim Reimbursement Mechanism (IRM) as a pandemic response, such as fund allocations being based on historical claims of health care institutions, thus not being targeted toward areas with high Covid-19 cases.
‘Upcasing’ cases
Quimbo said giving higher allocations to institutions with higher claims potentially favors institutions with historical fraud and “upcasing” cases. “IRM funds being used on non-Covid-19 cases crowds out emergency funds that are necessary to immediately provide hospital care to Covid-19 patients in this time of pandemic,” she said.
She noted that the state health insurer conducted a substantial overestimation of the total cost of benefit payments for Covid-19 in 2020, where the authorized IRM allocation was PHP26.8 billion as against the committees’ estimated cost of PHP3.3 billion.
“Since PhilHealth allowed mere suspicion or likelihood of having Covid-19 to become a basis of claiming benefits under their existing case rates, upcasing is essentially legitimized,” she said.
Under PhilHealth Circular 2021-0004 issued on April 8, 2021, the use of Debit-Credit Payment Method will facilitate the settlement of accounts payable to HCFs. The circular applies to in-process claims from accredited HCFs treating Covid-19 patients and facilities providing the PhilHealth Covid-19 testing package, with no unliquidated interim reimbursement mechanism fund balances on record, and whose accreditation is not currently suspended.
President Rodrigo Duterte earlier directed PhilHealth to expedite the payment of hospital claims. Duterte’s directive came after the state-run medical insurer earlier acknowledged delays in its processing of reimbursement claims by hospitals.
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