PhilHealth response to UPLIPP complaints

This is in response to the letters of the United Private Lying-In Practitioners and Proprietresses or UPLIPP (Opinion, 5/13/14 and 5/31/14).

Unpaid claims since August 2013. The record shows that PhilHealth Regional Office IVA (Proiva) has no claims backlog for 2013. In fact, PhilHealth’s February 2014 report shows that claims for December 2013 were paid within 20 days from filing, making Proiva the No. 1 PhilHealth regional office in “turnaround time” for processing claims.

Delayed payment of claims refiled in March 2014. Lying-in facilities or maternal care providers (MCPs) are aware that they have 60 days from the patient’s discharge to file the pertinent claim with PhilHealth; and PhilHealth has 60 days from  receipt of the claim papers to process/pay valid claims. A separate 60-day processing period is given for claims returned to the facility (RTH) due to insufficient requirements.

Assurance to prioritize UPLIPP claims. A total of P4,119,785 in checks for private MCPs in Cavite was delivered last May to our offices in that province, for pickup. Also, checks representing the total amount of P75,520 were personally handed over to MOMS Today Lying-In Clinic and Betonio-Bacuñata Medical Clinic during our May 12 meeting.

Unreimbursed claims. At present, Proiva has 2,207 claims (including those from Laguna and Quezon facilities) for processing. These are “current” claims received in May, hence still within the 60-day period for claims processing.

To date, PhilHealth has paid 1,674 claims amounting to P8,015,450; 263 are still being processed; 334 are RTH due to improperly filled-out claim forms; 486 have been denied for noncompliance with or nonsubmission of accreditation requirements.

For 2013, PhilHealth paid 10,165 claims from private lying-in facilities in Cavite with the total amount of P48.2 million, within 20 days from Proiva’s receipt of the claims.

Only 10 percent of total claims paid by PhilHealth. A random check on this allegation showed instead the following payment rate: Betonio-Bacuñata—28 percent; MOMS Today—38 percent; Jennifer A. Medillo Lying-In Clinic—65 percent; ACHAAH’s Lying-In Clinic—67.6 percent and Gina E. Gala Lying-In Clinic—56 percent.

Action taken by Proiva. When the “all case rate payment scheme” for the processing of claims was implemented last January, several technical glitches in the system were experienced. As a stopgap measure, since March 2014, Proiva has implemented shifting schedules for the encoders at the Benefits Administration Section (BAS). Also, selected employees from other divisions were temporarily assigned to BAS to assist in the processing of claims.

Dialogue with UPLIPP. In a meeting last June 4, Proiva presented the list of checks

issued to UPLIPP members, with a sample percentage computation of claims paid; and the list of UPLIPP members with denied claims due to the absence of valid PhilHealth accreditation. Those on the list were advised to call Dr. Edwin M. Oriña at any time regarding problems with their claims or accreditation.

—ALBERTO C. MANDURIAO,

regional vice president,

PhilHealth Regional Office IVA