The Puerto Princesa City Council has urged the national government to undertake a thorough review of the Philippine Health Insurance Corporation’s (PhilHealth) current guidelines in paying COVID-19 claims of hospitals and service providers.
The calls came following a public hearing on complaints that local hospitals were charging PhilHealth exorbitant amounts, taking advantage of its existing “case rates” system.
Local hospital representatives told the Council that PhilHealth guidelines allow them to claim the maximum case rate of P786,384 for all critical Covid cases that they handle and that it is up to PhilHealth to approve the claim.
“Ang issue sa akin ay ang paggastos at pagwaldas ng pera ng PhilHealth na galing sa mga nagko-contribute dito. Dahil sa puwede ma-claim na more than 700,000 na amount kung ang diagnosis ay COVID-19 pneumonia critical. Kung titingnan ninyo ang case rates, makikita ninyo ang pneumonia, ang claimable case rate is only P4,000. Why is it kapag COVID-19 critical bigla na lang naging P786,000? Para sa akin, with all due respect, ginagawa ninyo itong gatasan,” said City Councilor Atty. Herbert Dilig.
The councilors quizzed Ospital ng Palawan (ONP) officials for making P786,384 in PhilHealth claims on a deceased patient’s bill that they claimed was only worth P42,833.36.
ONP representatives explained that they apply the Critical Pneumonia package to all their COVID-19 cases, regardless of the actual billing amount. 70% of the total amount goes to the hospital’s pooled funds while 30% is labeled as “professional fees.”
“Sa case ng ONP, simula nitong January to June , mayroon na kaming 366 na tested positive for COVID-19, RT-PCR. May mga pasyente kami na umabot na ng P1-million plus ang gastos dahil sa itinagal nila sa ospital. Kahit na lumampas na ng P1.2, P1.1 million ‘yan ang aming fa-file-an ng claim is the maximum [P786,384]. ‘Yong difference sa one million doon sa P700[thousand] plus na bill, ‘yon ang magpapaliwanag na kahit less than the case rate ang actual bill,” said Gloria Bayaban, ONP head of administrative and finance.
PhilHealth said they evaluate the medical records before approving the payments.
“Sa processing namin ng COVID claim, ipapadala sa amin ng facility, and then dadaan siya ng medical evaluation where we require the complete medical chart [ng pasyente] para ma-evaluate ng doctor namin. After that, saka na siya ipo-proceed sa payment, or if denied, ibabalik namin,” said Maria Nimfa Bereña of the PhilHealth Region 4B Benefits Administration Section.
Adventist Hospital Palawan (AHP) chief operations officer Dr. Ian Kenneth Bermeo and Palawan MMG Cooperative Hospital medical hospital Dr. Paul Castillo said that their hospital also apply the same method, albeit in a more detailed manner. However, AHP, being a non-stock non-profit hospital, he said they do not use the 70% pooled fund and 30% professional fee breakdown, which the ONP uses for its PhilHealth remittances.
“’Yong claims [are the] same whether private or government hospital. May Mild, Moderate, Severe, or Critical. Kung pasok siya sa criteria, then after the review of PhilHealth, they will provide [remittance],” said Bermeo.
”It’s actually up to the PhilHealth to rank kung ilan ang ibibigay sa ospital. Pina-pass lang namin ang requirements at and all the hospital bills, but the PhilHealth decides whether [or not] to give the full amount to the hospital,” said Castillo.
After explaining that all claims sent to their office undergo thorough screening and auditing, PhilHealth regional officials added that the ONP’s COVID-19 claims are currently on hold for the same reason. The ONP also needs to be officially recognized by PhilHealth as a Level 2 facility, one of the pre-requisites to claim the Critical Pneumonia amount. ONP officials clarified during the session that they have already submitted the necessary paperwork to be classified as a Level 2 facility, and are also recognized as such by the DOH.