Dr. Edwin Mercado addresses journalists during his first press conference as president and CEO of PhilHealth at the state health insurer鈥檚 head office in Pasig City on March 6, 2025. PHOTO BY DEXTER CABALZA
MANILA, Philippines 鈥斅�The Philippine Health Insurance Corp. (PhilHealth) has committed to pay billions worth of unsettled claims to hospitals in the next six months.
According to PhilHealth, it will start with the 1.1 million previously denied claims stemming from late filing issues of hospitals that ballooned to P8.8 billion dating from 2018.
鈥淲e acknowledge the complaints of many different hospitals of their denied claims. Many of these are not fraudulent but due to being filed past the deadline or other administrative reasons. We are going to process these again so that the hospitals will have additional resources to accommodate more patients,鈥� Dr. Edwin Mercado Mercado said on Thursday during his first press briefing as president and CEO of PhilHealth.
Denied claims are requests to PhilHealth that have been determined to be 鈥渋nvalid and unworthy of payment or reimbursement due to an absolute deficiency that cannot be remedied through return-to-sender or due to a finding of an unmet requirement.鈥�
Based on its data, 30 percent of hospitals鈥� claims in the past seven years have been denied due to being filed by healthcare providers past the 60-day deadline under Republic Act No. 10606, or the National Health Insurance Act of 2013.
According to Mercardo, the massive undertaking is a crucial step towards improving healthcare access and reducing bureaucratic obstacles for patients and healthcare providers.
The state health insurer said by focusing on resolving the backlogs, it would enhance its service efficiency and 鈥渞ebuild trust in the national health insurance system,鈥� by providing much-needed financial relief to affected providers and patients who have been waiting for claim resolutions.
6 months聽
Under PhilHealth Circular No. 2025-006 released on Tuesday, PhilHealth will reprocess all claims previously denied due to late filing dating from Jan. 1, 2018 鈥� when the mandatory electronic processing claims system was first implemented 鈥� to Dec. 31, 2024.
The state health insurer shall give all concerned health facilities a six-month period 鈥� starting from the effectivity of the new policy on March 21 鈥� to resubmit their previously denied claims due to late filing along with the necessary documentary requirements.
These include 鈥渦nprotested鈥� and 鈥渦nappealed鈥� denied claims that the health facilities are still in the possession of; denied claims still in possession of the PhilHealth regional offices; and claims denied with finality that are pending before the courts, provided that the appellants withdraw their petition against PhilHealth.
This shall also cover denied claims under the Z Benefit and Outpatient HIV/AIDS Treatment packages, which are currently in manual mode of filing, filed during the same period.
However, the circular does not apply to claims that are already beyond the prescribed filing period, those that have never been received by PhilHealth, and claims that are still in possession of health facilities.
Also excluded from the circular are claims related to primary care benefits, the Konsulta outpatient benefit package, and other benefit packages that have separate filing guidelines and deadlines.
According to PhilHealth, the new policy 鈥渁ims to reduce claims denials, ensure reimbursement of valid claims, and improve relationship with health facilities.鈥�
鈥淭he intent behind this flexibility is to ensure that health facilities are fairly compensated for the services they have already rendered, even when delays in claims submissions occur due to circumstances beyond their control,鈥� the circular said.
Hard to comply with
Asked for comment, Dr. Jose de Grano, president of the Private Hospitals Association of the Philippines Inc., (PHAPI), said it might be difficult for their members to comply with the voluminous documentary requirements they need to submit within six months.
鈥淚t seems easy only per their announcement, but compliance of the facilities may be another thing. It feels like we鈥檙e still being made to suffer for the services we already provided,鈥� he said.
Still, they were 鈥渉appy鈥� for the newest policy of Mercado, whom he said as being a former private hospital administrator 鈥渃an understand the plight of the providers.鈥�
鈥淸But] of course, we reiterate that [to PhilHealth] that there are still P20 billion more claims which were unpaid and should be processed immediately since those were already services rendered and the hospitals have already suffered a lot for those unpaid claims,鈥� he told the Inquirer.
During a meeting with private stakeholders last month, Mercado said they would 鈥渟lowly look鈥� into the remaining 60 to 70 percent of denied claims, and study if there could be something done to address them.
According to De Grano, some hospitals鈥� claims were just denied 鈥渇or reasons unknown to members.鈥�
P60-B unpaid accounts
These claims were still being appealed, the PHAPI president noted, saying that these ballooned 鈥渢o more than P50 billion鈥� based on their own sources.
鈥淗owever, the hospitals are still asking for payment of those claims since the amount is quite big and it has caused a dent in the operating expenses of the hospitals, especially the private providers,鈥� he added.
During a House of Representatives committee on health hearing in January, PhilHealth revealed it has P59.6 billion in unpaid claims to hospitals, accumulating from 2018 to 2024.
Around 60 percent of these are denied claims amounting to P37.1 billion, while the remaining were 鈥渞eturn-to-hospital鈥� (RTH) claims, which contain clerical errors and are sent back to the healthcare providers for correction.
Once the errors are rectified, these RTH claims are considered as 鈥済ood claims,鈥� and are then paid by PhilHealth.