PhilHealth disburses P137B in claims from Jan. to Oct. 2024

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State health insurer PhilHealth paid a total of P137.6 billion in benefit claims to more than 12,000 accredited health care facilities nationwide from January 1 to October 31, 2024, with a national average turnaround time (TAT) of 25 days.

The said payment is P37.6 billion or 37.7 percent higher compared to the P99.9 billion payment made during the same period last year. The national average TAT for claims processing also significantly improved to 25 days which is 35 days faster than the 60 days prescribed under Republic Act No. 10606.

“The steady flow of payments and accelerated processing time are part of our commitment to provide timely and efficient support to our health care partners. The reduced turnaround time has been commended by partner hospitals around the country. It is helping them maintain liquidity, ensuring steady supply of medicines and supplies, salaries for health workers, and continuous improvement of facilities which all translate to better services to members,” PhilHealth President and CEO Emmanuel Ledesma Jr. said.

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The significant improvement in claims payments and faster turnaround time was recognized by the Agency’s partners and stakeholders.

Claims payments

Recently, Dr. Jose P. Santiago, Jr., President of Philippine Hospital Association said during the sidelines of a media event: “Marami nang pagbabago sa mga nakaraang buwan tungkol sa pagbabayad ng PhilHealth sa mga ospital. Personal na bumibisita (sila) sa mga ospital sa iba’t ibang regions para mag-reconcile at alamin ang mgaproblema. Dahil dito, nababawasan na ang negatibong issues sa pagitan ng PhilHealth at mga ospital, at nagkakaroon ng magandang relationship ang PhilHealth at PHA. Ramdam na namin ang pagbabago.”

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Sharing the same observation during a recent reconciliation claims conference with hospital leaders, Private Hospitals Association of the Philippines, Inc. President Dr. Jose Rene De Grano thanked PhilHealth for“their initiative to improve claims processing and (making) payment to hospitals better.” De Grano noted further that “for the past several months, we’ve seen significant improvements in claims processing, which hospitals can attest to, as they’ve acknowledged this positive change.”

Moving forward, the PhilHealth Chief has expressed hope that in due time, they will be able to address the remaining bottlenecks in claims processing through the use of Artificial Intelligence (AI). “We have just completed a study conducted by experts on how AI can aid us in receiving and processing claims at break-neck speeds never before seen,” Ledesma announced. “We are confident that with the support of our healthcare partners, this will happen in the very near future,” he added.

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‘Good’ claims

He also issued an appeal to healthcare facilities to invest in adequate and properly-trained human resource to ensure the submission of “good” claims within the prescribed filing period. “This will help ensure claims are complete and in order, free from deficiencies, incomplete documents or signatures, and unreadable attachments, among other reasons,” he said.

Claims are returned to the hospitals because of discrepancies in entries; incomplete, inconsistent or unreadable documents, and improperly completed claim forms. On the other hand, claims are denied payment due to late filing/re-filing, non-compensable cases, and confinement happened during which the hospital has accreditation issues.

“The strict review and adjudication of claims is in keeping with PhilHealth’s fiduciary responsibility to our members. This is helping us ensure that the funds entrusted to us by the Filipino people are spent judiciously and responsibly,” Ledesma stressed.

To lower the incidence of returned or denied claims, the state health insurer is reaching out to the hospitals around the country to inform and educate them on the latest claims policies, guidelines and pertinent requirements. It is also conducting claims reconciliation which was earlier validated by the PHA and PHAPi Presidents.

“These efforts ensure that hospitals are properly apprised of the true status of their claims. We trust that these will put into proper perspective the issue of alleged non-payment of claims,” the Chief asserted, adding that “PhilHealth is governed by pertinent laws and state auditing rules to ensure that every peso is spent prudently and transparently.”