GOOD CLAIMS LANG ANG BINABAYARAN NG PHILHEALTH; MAS MABILIS NA PAGBABAYAD SINIGURO

PILIPINO Mirror
Dante Gierran

TINIYAK ng Philippine Health Insurance Corporation (PhilHealth) sa mga accredited health care provider nito na babayaran nila sa takdang oras ang mga claim na walang deficiency at naaayon sa mga polisiya ng programa.

Ito ay sa gitna ng mga pahayag ng Private Hospital Association of the Philippines, Inc. (PHAPi) na umano’y hindi pagbabayad ng mga claim sa mga miyembro nitong ospital na umaabot sa P6 bilyon. Sinabi rin ng ahensiya na ang binigyang-tuon lamang sa usapin ay ang mga hindi bayad na claim at nalimutan ang P25 bilyon na nabayaran sa taong 2020.

Batay sa record, tumanggap ang PhilHealth ng kabuuang 3 milyong claims mula sa PHAPi member hospitals simula January hanggang December 2020, kung saan 87% ay nabayaran na ng P25 bilyon habang nasa 5% o nagkakahalaga ng mahigit sa P1 bilyon  naman ang nasa iba’t ibang estado ng pagpoproseso.

Samantala, sa kabuuang claims na natanggap, 8% na nagkakahalaga ng P2.4 bilyon ang ibinalik sa mga ospital (Returned-To-Hospital o RTH) at na-deny dahil sa mga deficiency o may violation sa mga umiiral na polisiya. Ilan sa mga karaniwang dahilan ng RTH ay unavailability/incompleteness/inconsistency/unreadability ng mga supporting documents, may iba pang dokumento na kinakailangan, may discrepancy sa mga entry, hindi napunan nang tama o may mali sa Claim Forms, at iba pa.

Ang mga kadalasang dahilan naman kung bakit nade-deny ang claim ay dahil sa hindi pagsunod sa standard of care (system), late filing, mga hindi binabayarang sakit sa ilalim ng case rate package, at iba pa.

“Ang mga miyembro natin ay umaasa na magiging maingat tayo sa paggastos dahil ang pondong ito ay ipinagkatiwala nila sa atin, kaya tinitiyak natin na ang bawat claim na binabayaran ay naaayon sa batas at sa mga regulasyon ng programa,” sabi ni Atty. Dante A. Gierran, Pangulo at Punong Tagapagpaganap ng PhilHealth. Aniya, ang PhilHealth ay saklaw ng auditing rules ng Commission on Audit.

Ayon pa kay Gierran, batid ng PhilHealth ang sitwasyon na kinahaharap ng maraming pasilidad ngayon sa gitna ng pandemya.

“Kami ay committed na bayaran ang good claims sa takdang panahon, ngunit kung may deficiency ay may mga batas at panuntunan na dapat sundin,” dagdag pa niya. Tiniyak din niya ang mabilis na claims processing na sa kasalukuyan ay umaabot lamang sa 39 araw sa buong bansa kumpara sa 60 araw na itinatakda ng batas.

Hinimok din ng ahensiya ang mga ospital na makipagdiyalogo at mag-reconcile ng records sa kanilang mga regional office upang malaman ang mga dahilan ng RTH at denied claims.

“Bukas po ang aming tanggapan sa lahat ng rehiyon para mag-reconcile ng claims records. Nakahanda kaming tulungan sila na makapag-comply sa mga polisiya para mabawasan kundi man maiwasan ang denied o pagbabalik ng claims sa mga ospital.”

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