Several lawmakers on Friday accused the Philippine Health Corp. of delaying or denying hospital claims due to "mechanical" reasons.
At the House Committee on Good Government and Public Accountability's hearing on alleged anomalies at PhilHealth, Marikina City Rep. Stella Luz Quimbo questioned if the reasons given by PhilHealth officials could be deemed as fraudulent acts.
At the same hearing, a PhilHealth official said the state insurer had only six years to go at the rate it was operating.
"The estimated actuarial life for now is until 2027," PhilHealth's acting Senior Vice President Nerissa Santiago told congressmen.
"That means the reserves and the expected collections as against benefit payouts, are only enough until 2027," Santiago said.
Santiago however added, “this is only based on projections, noting that assumptions could be different from what will really transpire in the future. It will depend on the subsidy from the government with respect to the premium contribution for the indirect distributors."
"It will also depend on the rollout of benefit enhancement in the future. actuarial life depends on many factors," she added.
Santiago said the state insurer expected a net loss of some P57 billion in 202].
Quimbo said it was unacceptable that PhilHealth could only last until 2027.
"That’s not an acceptable idea and from January to June you earned much. In fact if you continue to collect as much of what you collected last year, which is P149 billion, that means you will collect, say P50 billion in the next six months," Quimbo said.
On the denial and delay in the payment of claims, Quimbo said even claims that were not believed to be fraudulent were being denied or the payments were being delayed.
In the same briefing, PhilHealth officials said the most common reasons for claims ageing beyond 60 days were:
• No value has been set for patient priority subgroup;
• No value has been set up for services covered in COVID testing claim;
• Without attached valid itemized billing;
• No value has been set for the flag indicating whether test kits have been donated or not;
• Without attached valid case investigation form;
• Without attached valid SARS-COV-2 claim summary form;
• Required document is unavailable/incomplete/inconsistent/unreadable;
• Filed beyond 120 days statutory period;
• No applicable entry found in the benefits library; and
• Double filing/same day confinement
Given all these, Quimbo said she saw no reason "why the claims should age beyond two months."
She pressed PhilHealth if there was an indication of fraud.
"If you deny a claim, one reason is that they didn't meet the statutory requirements and number two, it should be suspected of being fraudulent," she said.
PhilHealth's Jonathan Ele said that double filing or same day confinement could be considered fraud.
