This has reference to the allegations made recently by Dr. Rustico Jimenez, President of the Private Hospital Association of the Philippines, Inc., that PhilHealth owes a number of their member hospitals around P7 to 9 billion in alleged unpaid claims.

This was first made public by Dr. Jimenez on May 8, 2018 in an interview during Kabayan Noli de Castro’s program at DZMM where he mentioned of only 15 hospitals reportedly with receivables of P7 to 9 billion.

We later found out that there are 24 hospitals in the list (please see screenshot below of actual list that Kabayan Noli’s staff has provided us upon our request) with a combined total of only P743.3 million in alleged unpaid claims. Please note that Dr. Jimenez did not specify in their list details like coverage period within which these claims come from, among others.

We immediately looked at the claims profile of a randomly chosen 12 hospitals in his list (as the others are with similar names still needing clarification from Dr. Jimenez) and found out that PhilHealth have paid them a total of Php3.75 billion already for the period 2014 to 2018.

We shall soon be coming up with a complete report covering all 24 hospitals in their list.

Per PhilHealth records from its Corporate Dashboard, claims that are still “in-process” for the same period (2014-2018) have totaled to 5,085 claims (as of May 9, 2018) amounting to only P50.85 million, which is just 0.73% and far lower than the P7 or so billion in their purported receivables.

Below is the table of the status of “in-process” claims for reference:

It should also be noted that there are 7,602 claims that were denied payment while another 10,714 claims were returned to their respective hospitals for compliance, also on the same period.

Summing up PhilHealth’s payments of P3.75 billion and another P50.85 million in impending payments for “in process” claims on record, less those already denied payments and returned-to-hospital claims (7,602 + 10,714 claims = 18,316 claims x P10,000 Average Value Per Claim = P183.2 million) quickly gives us an idea how overly bloated PHAPI’s claims are against the state health insurance agency.

On the alleged slow payment as a result of e-claims:

Contrary to Dr. Jimenez’s assertion that PhilHealth is delayed in paying their member-hospitals due to the implementation of the e-Claims system in 2017, our Corporate Dashboard shows that we are paying hospital claims at an average of 50 days nationwide, with the shortest average claims processing time at 38 days for those submitted through third party solutions providers under the new system being criticized by the PHAPI.

By law, PhilHealth has 60 calendar days to process and pay hospital claims.

The PhilHealth e-Claims Submission System aims to reduce the turn-around-time and improve operational efficiency in the processing/payment of claims. It enables the encoding of claims information in the hospital systems, and submission online via PhilHealth Web Service. It also provides our institutional health care providers with a facility to view the status of their claims online.

In summary, our initial data analytics shows that the allegations of Dr. Jimenez on the alleged unpaid claims are erroneous and inaccurate.

Please be assured that we shall seek an audience with them soon so we can properly thresh out these issues and work together for the immediate resolution of the matter for the benefit of our members and partner hospitals.

Our immediate action steps:

It behooves upon us PhilHealth to act on whatever issues and concerns that our members and stakeholders may have for the betterment of their National Health Insurance Program.

Hence, we are implementing the following steps and actions to immediately resolve this issue:

• • We will come up with a reconciliation portal for our partner hospitals to readily provide them with a summary of their good, pending, denied and in process claims. This is an added feature that will promote better efficiency and transparency.
• • Formation of a task force that will review and expedite payments of unpaid claims, if any.
  
  We shall be looking into the claims data not just of PHAPI members but of all our accredited facilities in the government and private sectors to see if there are weak areas that we need to improve on, and other areas as well to continue building our strengths on.