ARTA cites 3 reasons behind delays in PhilHealth's payment of hospital claims

The Anti-Red Tape Authority (ARTA) has identified at least three causes of delay in the Philippine Health Insurance Corporation's (PhilHealth) processing of payments of hospital claims amid the coronavirus (COVID-19) pandemic.

Anti-Red Tape Authority (ARTA) and Philippine Health Insurance Corporation (PhilHealth) logos

ARTA Director-General Jeremiah Belgica made the statement as PhilHealth continues to be under fire for the delays in its payment of COVID-19 reimbursement claims from both public and private hospitals.

In a statement, Belgica pointed out PhilHealth's issues with its Information and Communications Technology (ICT), wrong diagnoses and faulty documentation in its Return-to-Hospital (RTH) applications, and Medical Prepayment Review (MPR).

The agency likewise found that PhilHealth continues to struggle with its lack of manpower amid the pandemic, a common problem among government agencies.

Belgica said the initial findings which were first revealed to Congress on August 26 were sourced from ARTA's series of meetings with PhilHealth and concerned public and private hospitals.

"We do support PhilHealth in its streamlining efforts," Belgica said during the hearing.

"We will be committing to helping them," he added.

In a previous meeting with ARTA, PhilHealth officials pointed out their problematic internet connection and lack of cloud storage that hamper their operations.

Belgica referred PhilHealth to the Department of Information and Communications Technology (DICT) that in turn pledged to assist them with their storage concerns. However, PhilHealth will have to resolve its internet speed issues on its own since it will be coordinating with its internet service provider.

Data from PhilHealth showed that of the number of applications with them, 76.35 percent have been paid, 11.88 percent are being processed, and 3.47 percent have been denied.

Only 8.30 percent are RTH applications. Of this figure, approximately .64 percent are because of wrong diagnoses.

ARTA recommended PhilHealth to conduct a streamlined pre-assessment or pre-payment review of documentary materials, post-evaluation audit, and automation to improve their services.

"For pre-payment assessment, they can do a risk-based assessment. Sino unang babayaran? Baka may maliliit na health institutions na magsasara kung hindi binayaran (Who should they pay first? There might be small health institutions that are forced to close down if they are not paid)," Belgica said.

He likewise suggested PhilHealth apply credit standing-based to determine institutions with a good record and have not failed in their diagnoses.

Meanwhile, another issue that was taken up during the hearing was PhilHealth's 60-day period to liquidate its cash advances to the Commission on Audit (COA) after distribution to regional hospitals and offices.

The Ease of Doing Businesses Act of 2018 has a so-called "3-7-20 rule" wherein simple government transactions must be finished in three days, complex transactions in seven days, and highly technical transactions in 20 days.

However, Belgica said this is "water under the bridge" because the process requires even more than 60 days to finish.

He recommended the creation of law regarding the 60-day period to liquidate cash advances to COA for PhilHealth to follow. Belgica said government transactions that do not indicate the period needed to finish them are illegal.

In the meantime, ARTA said it will summon all regional offices of PhilHealth to ensure the speedy payment of hospital claims following the directive of President Duterte.

He, however, said that if the state insurer's regional offices fail to act within the 60-day period, then the Authority will be compelled to implement its enforcement function as mandated by the law.