PhilHealth to settle previously denied hospital claims

Metro Manila, Philippines – The government health insurer said it received the green light to settle billions of pesos in previously denied hospital claims mostly due to late submission of requirements.

“Last week, we received already the response from the OGCC (Office of the Government Corporate Counsel) that the corporation can pay these accounts,” Renato Limsiaco Jr., Philippine Health Insurance Corporation (PhilHealth) PhilHealth senior vice president for fund management, said in a Senate hearing on Thursday, Jan. 16.

“Meaning, even na-deny na siya in the past due to late submission, ito po ay babayaran ng corporation once it will be approved by our Philhealth board [Meaning, even if it was previously denied due to late submission, it will still be paid by the corporation once approved by our PhilHealth board],” Limsiaco said.

He made the statements in response to questions from Senator Christopher “Bong” Go, chairman of the committee on health, regarding the up to P6 billion in unpaid claims to private hospitals and over P14 billion to government hospitals.

Limsiaco said PhilHealth has only P2.68 billion in "in-process claims" from private hospitals between 2018 and 2023. He explained that private health facilities may be referring to the denied or Return to Hospital (RTH) claims.

Claims are denied if deemed "invalid and unworthy of reimbursement due to an absolute deficiency" or if filed beyond the 60-day deadline.

RTH claims, on the other hand, are deficient claims that, after adjudication and validation, are sent back to the health care institutions for required corrections. Once resubmitted, the claim may be approved or denied based on compliance.

In a previous House hearing, Limsiaco said the denied and RTH claims totaled P59.6 billion from 2018 to 2024. It remains unclear which claims will be settled, as Limsiaco noted that the PhilHealth board, chaired by Health Secretary Ted Herbosa, must first approve the payments.