House bill grants amnesty to hospitals amid P59.6-B unpaid PhilHealth claims

A BILL granting amnesty to hospitals with denied reimbursement claims, embroiled in legal disputes with the Philippine Health Insurance Corp. (PhilHealth), has been filed at the House of Representatives.

The state health insurer has P59.6 billion in unpaid claims to hospitals, which it accumulated from 2018 to 2024, PhilHealth Senior Vice-President Renato L. Limsiaco, Jr. told lawmakers during a House hearing on Wednesday.

“I have filed a House bill giving amnesty to these denied claims because of late submissions and return-to-hospitals [claims] because of small discrepancies [in reimbursement forms],” Party-list Rep. Wilbert T. Lee said during the same hearing.

House Bill (HB) No. 11298, filed on Monday, aims to ease the strain experienced by hospitals amid “legal battles resulting from payment delays, disparities in claims processing, and other compliance difficulties,” the bill’s explanatory note read.

Philippine hospitals file reimbursement claims to PhilHealth for the accrued costs of medical services provided to Filipinos, which is then deliberated by the state health insurer to determine its validity for compensation.

Processed claims which PhilHealth finds worthy of repayment are tagged as a “good claim,” according to a 2021 PhilHealth memorandum; while reimbursement requests seen as “deficient” are categorized into return-to-hospital (RTH) and denied claims, which leads to it being unpaid.

The Health department last week noted that most claims are denied as hospitals exceed the 60-day deadline for filing reimbursement claims.

HB No. 11298 proposed to automatically dismiss year-old pending cases against hospitals filed by PhilHealth for “suspected fraudulent activities.” The state health insurer should also reassess claims due to late form submissions prior to 2018, provided that hospitals demonstrate their delays were caused by “circumstances beyond their reasonable control.”

“[Granting] amnesty by facilitating the payment of denied claims due to late filing will help healthcare providers recover from financial strains and ensure continued operation and the availability of services to the public,” the proposed law stated.

Mr. Lee’s amnesty bill is “untenable,” Iloilo Rep. Janette L. Garin said. “It will be very difficult for PhilHealth to do that because they will now be the subject of a lot of cases,” she told lawmakers during the same House hearing.

PhilHealth should instead fast-track its digitization efforts to curb denied and RTH claims to hospitals, she said. The state health insurer started automating its claims system in 2018.

Reimbursement claims are often returned or denied for minor documentary discrepancies due to manual processes, PhilHealth Senior Vice-President Israel Francis A. Pargas said in the same hearing.

The state health financier has received more than 101 million reimbursement claims amounting to P985 billion since 2017. Of this, it has settled 93 million claims worth P899 billion, according to its presentation during the House hearing. — Kenneth Christiane L. Basilio