18 September 2021 – Secretary Jeremiah Belgica, Director General of the Anti-Red Tape Authority (ARTA), said the payment recovery policy of the Philippine Health Insurance Corporation (PhilHealth) will help speed up the processing of the unpaid COVID-19 claims of hospitals.
PhilHealth Circular No. 2021-0011 states that the PhilHealth Payment Recovery (PPR) policy will be used for the settlement of accounts of health care providers relative to fines, penalties, or overpayment of claims to ensure funds due to the state insurer will be accounted accordingly.
This, as PhilHealth was given more flexibility in making the Debit-Credit Payment Method (DCPM) available to all hospitals and not just those that are in COVID-19 hotspot areas.
The Inter-Agency Task Force for Emerging Infectious Diseases (IATF-EID) lifted the limitations on the coverage of the DCPM upon the recommendation of ARTA and PhilHealth.
The PPR policy will also help protect PhilHealth from losses as it explores the possibility of conducting its Medical Prepayment Review (MPR) post-audit to expedite the release of payment for the COVID-19 hospital claims.
This was another one of ARTA’s recommendations after it was presented with figures that show that only a fraction of the applications with PhilHealth contain wrong diagnoses.
“Maganda po iyan. Mapoprotektahan kayo nito from losses due to claims with erroneous diagnoses, among other reasons, at dahil diyan, mapapabilis din nito ang pagproseso niyo ng bayad para sa mga ospital,” Belgica said, addressing PhilHealth.
“Hindi nila masasabi na malulugi kayo kasi mababawi ninyo agad,” he added.
The payment recovery mechanism can be used when a medical post-audit reveals an upcasing or creeping of claims; when the payment of claims is credited to the wrong facility; when the payment of claims was made during the lapse or gap in accreditation validity or DOH license validity, the suspension or after the removal of a particular service, or during the withdrawal, non-renewal, suspension of accreditation, or closure of the health care provider; and when overpayments are made to the health care provider due to administrative discrepancies.
Republic Act No. 7875 or the National Health Insurance Act of 2013 authorizes PhilHealth to deduct the imposable fine from the pending benefit claims of health care providers.
PhilHealth’s circular also states that it can employ other means, such as but not limited to, sending demand letters and exhausting all legal avenues, including the filing of criminal charges, if warranted to recover the due amount.
If there are health care providers who have any contention of the policy or on the payment being recovered from them, the processing of benefit claims will continue and the PPR policy will not apply pending resolution of the issue by the PhilHealth Regional Office (PRO) Legal Services Unit.
PhilHealth has been under fire for its delayed disbursement of payment for the COVID-19 claims of both public and private hospitals. Recently, President Rodrigo Roa Duterte called on the state insurer to release the payments so the hospitals and other health facilities can continue their operations.
The Authority has had several meetings and hearings with PhilHealth, along with other government agencies, concerned groups, and private stakeholders.
ARTA has also formed a support group composed of officials from the Department of Health (DOH), Food and Drug Administration (FDA), Health Technology Assessment Council (HTAC), and Department of Information and Communications Technology (DICT) to further assist PhilHealth with its issues.
It will also invite the Office of the Presidential Adviser for the Streamlining of Government Services (OPASGP) to join the group and the Commission on Audit (COA) to serve as resource speakers.
The group will conduct more meetings in the coming days.