New PhilHealth chief seeks faster processing of claims

By John Victor D. Ordoñez, Reporter

THE newly appointed chief of the Philippine Health Insurance Corp. (PhilHealth) on Wednesday vowed to speed up the processing of healthcare claims and expand the benefits for members, calling systemic problems of the agency as “illnesses” that should be treated.

“Hopefully, we can release new procedures to identify the causes and expedite minor issues,” PhilHealth President and Chief Executive Officer Edwin M. Mercado told a news briefing at the presidential palace in mixed English and Filipino.

“This will not only be prospective but also retroactive. We will review the old denied claims and determine what can be paid if the basis is set in compliance with Commission on Audit (CoA) rules,” he added.

Mr. Mercado, a US-trained orthopedic surgeon with 35 years of experience in hospital management, replaced Emmanuel R. Ledesma, Jr., who was criticized for failing to increase members’ benefits even after the agency declared excess funds worth P90 billion.

In October, the Supreme Court  blocked the transfer of P29.9 billion — the last tranche of PhilHealth’s P89.9 billion in excess funds — to the national Treasury.

Mr. Mercado got his medical degree from the University of the Philippines in 1987 and a master’s degree in medical sciences at Harvard Medical School in 2023.

He was also a lecturer at the Ateneo School of Medicine and Public Health on medical research methods and implementation science.

The surgeon has been a fellow at the Brigham and Women’s Hospital Division of Global Health Equity since July 2023, where he studies the use of artificial intelligence as a tool for community health workers.

Congress in December stripped PhilHealth of P74 billion in subsidy this year, citing its nearly P90-billion reserve funds that could be used to increase members’ benefits.

Senator Joseph Victor G. Ejercito, the primary author of the Universal Health Care Act, urged the new PhilHealth chief to avoid treating the agency as a private, profit-driven corporation and focus on reducing the out-of-pocket medical costs borne by Filipinos.

“PhilHealth’s coverage of every Filipino’s hospital and medical expenses must significantly improve in line with universal healthcare’s vision of reducing out-of-pocket costs to ease the burden on every family,” he said in a statement.

In August, the Senate passed on final reading a bill that seeks to cut PhilHealth premiums to 3.25% this year from 5% last year under the Universal Health Care Act.

It sets PhilHealth premium contributions at 3.25% for those with a monthly income of P10,000 to P50,000, with incremental increases of 0.25% each year

Mr. Mercado said he seeks to work with other agencies with robust information technology systems (IT) to boost the agency’s digital infrastructure.

“Shifting to a new system is not easy, as I experienced when I was running a chain of hospitals,” he said. “The go-live, when everyone transitions to the new system, involves a lot of debugging — it can take years; but we will prioritize immediate aspects like claims adjudication.”