The Philippine Health Insurance Corporation (PhilHealth) announced on Thursday, March 6, that it will reprocess 1.1 million previously denied claims worth approximately P8.8 billion to clear the backlog caused by late hospital filings and ensure timely compensation for healthcare providers.
Such move, according to the state health insurer, underscores the PhilHealth Board and Management’s commitment to easing administrative burdens and ensuring healthcare providers receive due compensation.
“By focusing on resolving these delayed claims, PhilHealth aims to enhance its service efficiency and rebuild trust in the national health insurance system, potentially providing much-needed financial relief to the affected providers and patients who have been waiting for claim resolutions,” PhilHealth stated.
During a press briefing at the PhilHealth Central Office in Pasig, PhilHealth President and CEO Dr. Edwin Mercado said that the reprocessing of these claims, which were initially denied due to administrative reasons rather than fraud, is expected to enhance healthcare access and simplify bureaucratic procedures for both hospitals and patients.
“Alam nating matagal nang hinaing ng iba’t ibang mga ospital ang denied claims. Marami sa mga sinumiteng claims na ito ay denied dahil lagpas na sa deadline o iba pang mga administrative reasons at hindi naman dahil sila ay fraudulent (We know that hospitals have long raised concerns over denied claims. Many of these claims were denied due to late submission or other administrative reasons and not because they were fraudulent),” he said.
“Ang mga ito ay ating muling ipo-proseso upang ang mga ospital na naghatid ng serbisyong kinakailangan ng ating mamamayan ay mabayaran (We will reprocess them to ensure that hospitals that provided necessary services to our citizens get paid),” he went on.
From 2018 to 2024, the state health insurer reported that 30 percent of all denied claims were due to late filing.
Recognizing the impact of these denials, Mercado assured President Marcos that PhilHealth will reconsider these claims to guarantee healthcare providers receive proper remuneration.
Under the new policy, which was published on Thursday, March 6, in a national newspaper, hospitals and other health facilities will be given six months from the effectivity date of the Circular to resubmit previously denied claims that were rejected due to late filing.
PhilHealth stated that claims that were filed between Jan. 1, 2018, and Dec. 31, 2024, and were not protested or appealed but remain in the possession of healthcare providers will be eligible for reprocessing.
As such, the agency said claims in the possession of PhilHealth Regional Office Benefit Administration Sections, those under administrative protest at the PhilHealth Regional Office – Claims Review Committee or on appeal at the Protest and Appeals Review Department, and claims previously denied with finality per existing Implementing Rules and Regulations (IRR) from Jan. 1, 2018, to Dec. 31, 2024, will also be reconsidered.
Claims denied with finality due to late submission that have been elevated to regular courts will be reprocessed, provided that appellants withdraw their petition against PhilHealth, it added.
Despite this reconsideration, the PhilHealth chief reminded hospitals of the importance of timely claim submission to ensure prompt payments.
“Ang pagpaparamdam ng alagang pangkalusugan ay isang coordinated effort kung saan ang PhilHealth ay tumutulong na pagaanin ang gastos para rito. Sa kabilang banda, kinakailangan din na alam ng PhilHealth ang mga serbisyong inihatid ng ating providers. Kaya naman, patuloy pa rin nating pinaaalala ang agarang pag-file ng claims upang mas mabilis nating mabayaran ang mga ito (Providing accessible healthcare is a coordinated effort where PhilHealth helps ease financial burdens. However, PhilHealth also needs to be informed of the services delivered by providers. That’s why we continue to remind them to file claims immediately so we can process payments faster),” said Mercado.