3 November 2021 – The Anti-Red Tape Authority (ARTA) served a show-cause order against two officials of the Philippine Health Insurance Corporation (PhilHealth) on Tuesday.

This, after it was learned that the state insurer has yet to release the payment for the unpaid claims of seven health care institutions in Iloilo City.

According to the presentation of PhilHealth Regional Office VI to ARTA, the total amount claimed by the seven hospitals is at least P690,016,959.81.

In the course of the proceedings between PhilHealth, ARTA, and the involved hospitals, it was seen in the time table that the state insurer was to pay the hospitals’ unpaid claims by the end of October.

The PhilHealth officials are given seven working days from the receipt of the order to explain the delay in payment.

If their response is found to be insufficient, they may face charges for violation of Republic Act No. 11032 or the Ease of Doing Business and Efficient Government Service Delivery Act of 2018.

On 22 October 2021, the hospitals called out PhilHealth for its long overdue unpaid claims. The health care institutions asked the state insurer for the immediate reconciliation and payment of claims and the immediate suspension of the policies for no co-payment and no-balance billing.

The seven involved hospitals are Iloilo Mission Hospital, St. Paul’s Hospital of Iloilo, Iloilo Doctors’ Hospital, Medicus Medical Center, The Medical City of Iloilo, Qualimed Hospital Iloilo, and the Metro Iloilo Hospital and Medical Center Inc.

Secretary Jeremiah Belgica, ARTA Director General, acknowledged that some PhilHealth officials have been cooperative in the Authority’s, along with other government agencies’, efforts to streamline its processes.

However, he said officials of the state insurer must explain themselves as some of the claims date back to several years ago.

“We want them to explain kung bakit hindi pa nila binabayaran ang mga ospital. Considering na matagal na, dapat binayaran na nila ‘yon. They should just pay and do a very efficient post audit afterwards,” he said.

“For whatever policy or actuarial reason, the hospitals should not be made to suffer because all of their suffering ultimately redound to the disadvantage of the people serviced by hospitals,” he added.

One of the issues that ARTA found with PhilHealth’s processing of payment for hospital claims is the tedious review of applications since some of them display wrong diagnoses and faulty documentations. But data showed that only .8 of the Return-to-Hospital applications that PhilHealth receives contain wrong diagnoses.

With this, ARTA recommended PhilHealth to conduct a streamlined pre-assessment or pre-payment review of documentary materials, post-evaluation audit, and automation to improve their services.

On September 2021, the Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF) approved the recommendation of ARTA and PhilHealth to lift the limitations on the coverage of the debit-credit payment method (DCPM).

This will allow PhilHealth to be more flexible in applying the DCPM’s coverage, should its board decide to do so. This is part of the plan to make the DCPM available to all hospitals, that will expedite the release of payment for COVID-19 claims made by both public and private hospitals.

Prior to this, the DCPM was only available to high and critical risk areas as determined by the Two-Week Growth Rate (TWGR), Average Daily Attack Rate (ADAR), and Health Care Utilization Rate (HCUR).

Sec. Belgica also cited the PhilHealth Payment Recovery Policy, that allows the state insurer to settle the accounts of health care providers relative to fines, penalties, or overpayment of claims to ensure that the funds due them will be accounted accordingly and that they will be protected from losses.

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.

The ARTA chief reminded PhilHealth offices to abide by the 60-day period that they are provided to process hospital claims as stated in their special law. He also encouraged hospitals in other parts of the country to not hesitate to seek ARTA’s help if they are experiencing similar issues.

Through various hearings, the Authority identified three key issues with PhilHealth’s processing of hospital claims: their Information and Communications Technology (ICT), wrong diagnoses and faulty documentation in its RTH applications, and MPR.

ARTA already connected PhilHealth with the Department of Information and Communications Technology (DICT) to resolve its storage issues. However, PhilHealth will have to resolve its internet speed issues on its own since they will be coordinating with their internet service provider.

The Authority also formed a “support group” comprised of members of various government agencies to help PhilHealth disburse the payment for the unpaid hospital claims.

Officials from the DICT, Office of the Presidential Adviser on Streamlining of Government Processes (OPASGP), Department of Health (DOH), Food and Drug Administration (FDA), and Health Technology Assessment Council (HTAC) comprise the support group. Representatives from the Commission on Audit (COA) have also been invited to serve as resource speakers.