A new bill proposing amnesty for hospitals facing denied reimbursement claims from the Philippine Health Insurance Corp. (PhilHealth) has been introduced at the House of Representatives. The bill, House Bill No. 11298, seeks to alleviate the legal and financial burden on healthcare institutions caused by recurring payment delays and issues with claims processing. According to Senior Vice-President Renato L. Limsiaco Jr., PhilHealth has accrued approximately P59.6 billion in unpaid claims between 2018 and 2024. These delays have significant financial implications for hospitals, affecting their ability to provide continuous quality healthcare services.
PhilHealth’s evaluation process classifies claims as “good claims” if validated for reimbursement, while claims deemed incomplete or illegitimate are classified as return-to-hospital (RTH) or outright denied, resulting in nonpayment. The Department of Health pointed out that many claims are rejected because hospitals fail to meet the 60-day deadline for submission. House Bill No. 11298 proposes to dismiss pending cases of suspected fraud that are older than one year and reassess claims predating 2018, acknowledging that such delays were beyond the hospitals’ control. Granting amnesty for these late claims is suggested to financially stabilize healthcare providers, thus ensuring continuous availability of medical services to the public.
The Argument for Amnesty
Supporters of the bill argue that the proposed amnesty is vital for keeping hospitals financially afloat, especially amid a backlog of claims and a cumbersome reimbursement process. The principal aim is to ensure that hospitals receive due payments, which would significantly alleviate their financial strain and maintain an accessible healthcare system. Hospitals have been grappling with labor and resource constraints, which are exacerbated by delays in reimbursement. Without a stable financial situation, hospitals might face difficulty in acquiring essential medicines, upgrading medical equipment, and remunerating their staff adequately. This could have a downstream effect on the quality of patient care and healthcare services’ sustainability.
Moreover, automatic dismissal of year-old pending fraud cases would mark a pivotal change in easing the legal burden on hospitals. Lengthy investigations and ongoing legal battles drain resources and add to the operational challenges that healthcare providers already face. By shifting the focus to reassessment and expedited processing, institutions can redirect their efforts to improving clinical outcomes and patient satisfaction. This amnesty, therefore, becomes crucial in creating a more streamlined, efficient system that could support hospitals and, by extension, the patients they serve.
The Opposition’s Concerns
Despite the potential benefits, some lawmakers and healthcare experts have raised significant concerns about the proposed amnesty. Iloilo Rep. Janette L. Garin, for instance, labeled the bill as “untenable,” arguing that it might open PhilHealth to numerous legal disputes. Rep. Garin recommended that PhilHealth should instead accelerate its digitization efforts to reduce manual errors that often lead to claim denials or rejections. PhilHealth began its digitization process in 2018; however, the transition has been slow, and a significant number of claims continue to be processed manually, leading to high instances of minor errors.
PhilHealth senior executive Israel Francis A. Pargas noted that many reimbursement claims are denied due to small, avoidable mistakes typically arising from manual documentation processes. The organization has processed over 101 million reimbursement claims amounting to P985 billion since 2017; of these claims, 93 million have been settled totaling P899 billion. Critics argue that investing in advanced, automated systems would significantly reduce the occurrence of minor errors, leading to fewer denied or RTH claims. This approach, they maintain, would be more sustainable and efficient than granting amnesty, which could potentially set a confusing precedent and complicate future claims processing.
Streamlining and Automation as Alternatives
A new bill has been introduced at the House of Representatives proposing amnesty for hospitals dealing with denied reimbursement claims from the Philippine Health Insurance Corp. (PhilHealth). House Bill No. 11298 aims to alleviate the legal and financial burdens on healthcare institutions caused by ongoing payment delays and issues with claims processing. PhilHealth Senior Vice-President Renato L. Limsiaco Jr. noted that approximately P59.6 billion in unpaid claims have accumulated between 2018 and 2024. These delays severely impact hospitals’ ability to provide consistent quality healthcare services.
PhilHealth classifies claims as “good claims” if validated for reimbursement, while incomplete or illegitimate claims are labeled as return-to-hospital (RTH) or outright denied, leading to nonpayment. The Department of Health noted that many claims are rejected because hospitals miss the 60-day submission deadline. House Bill No. 11298 proposes dismissing pending fraud cases older than a year and reassessing claims dating before 2018, recognizing that such delays were beyond hospitals’ control. Granting amnesty for these late claims could financially stabilize healthcare providers, ensuring continuous medical services for the public.