PhilHealth continues to improve its healthcare insurance systems and services to members

CEBU CITY—PhilHealth continues to improve the health care insurance systems and services in the country and reported to have paid over P20.1 billion to hospitals claims nationwide and P1,091,005,063 billion for Central Visayas from December 27, 2024, to January 25, 2025 representing a 38 percent increase from the previous year’s disbursement of P14.5B nationwide.

Marjorie Cabrieto, PhilHealth-7 Regional Vice-President revealed that these figures were disbursed to claims of all types of health packages and services rolled out for PhilHealth members nationwide as part of the government’s Universal Health Care program. The roll out of comprehensive health services now includes preventive oral health, physical medicine rehabilitation, and pediatric optometric services for children aged 0-15.

In a Kapihan sa Bagong Pilipinas discussions on February 11 at the PhilHealth Regional Office VII Training Room, 7th floor Skytower, N. Escario corner Acacia Street, Cebu City, Cabrieto said that the program aims to provide various assistive devices and financial support for common illnesses, with a recent 50 percent increase in coverage to enhance universal health care.

Emphasis is placed on adherence to the no co-payment policy and transparency in service delivery and mentioned the importance of data collection and consultation with associations before introducing new packages. Various heads and their roles in different regions are listed, highlighting the coordination and implementation of these health services.  

Cabrieto also discussed the integration of COVID guidelines into the service rollout, mentioning that over 200 combined services are managed and she expects for a swift implementation of the guidelines because all circulars and advice for the rollout can be accessed on the PhilHealth website.

“On the inclusion preventive oral health services covers exams, cleaning, fluoride varnish, and sealants while the integration of physical medicine rehabilitation and assistive devices in the program also include wheelchairs, walkers, and crutches.  The program also includes pediatric optometric services for children aged zero to 15 years old, covering eye and vision assessments, prescription glasses, and follow-up check-ups,” Cabrieto added.

She said that the changes are described as transformative, focusing on building a stronger foundation for universal health care with a 50 percent increase in financial support for common illnesses and diseases, aiming to provide greater financial relief.

The field health service costs will not be reduced and urges strict adherence to the co-payment policy, stressing the importance of transparency and adherence to the no co-payment policy to ensure the success of the program.

PhilHealth continues to monitor and improve in healthcare benefits and claims processing

PhilHealth said that the company continues to implement improvements in healthcare benefits and claims processing highlighting a reduction in claims processing time from 19 to 17 days, well under the 60-day requirement in close partnerships with healthcare providers, timely payments, and a 38 percent increase in health payments year-over-year.

Reconciliation efforts with facilities are ongoing, addressing deficiencies and ensuring accurate benefit claims, noting legal and accounting personnel working closely to facilitate claim statuses and improve compliance.  Despite some challenges in collecting from members, the focus remains on enabling timely and accurate healthcare payments, PhilHealth said.

Cabrierto said that PhilHealth follows up healthcare facilities on any deficient or delayed claims and engages with them to educate them on the organization's policies and claims submission processes. She noted that the average claims processing time has been reduced from 19 days to 17 days, significantly faster than the 60 days required by the IRR for the various benefit packages for different health conditions, including heart valve surgery, children with disabilities, prostate and cervical cancer, and open-heart surgeries.

According to PhilHealth, continues engagement with doctors and legal teams to ensure compliance with policies and reduces deficiencies in claims and commitment to partnering with healthcare providers by addressing payment delays and streamlining reimbursements.

PhilHealth said that there are challenges in claims management as well as solutions with ongoing reconciliation efforts with facilities to ensure accurate benefit payments and address any discrepancies, Cabrieto mentioned the involvement of accounting personnel from healthcare facilities to facilitate the reconciliation process.

“Some healthcare facilities collect payments from members on a daily basis and some claims are denied or delayed.  These can be a challenge but continuous engagement with healthcare facilities helps in resolving these issues,” Cabrieto said.

The continuous engagement with healthcare providers to ensure timely and accurate claims processing; update policies, provide seminars to keep healthcare providers informed and compliant and the role of reach out teams in providing support and information to healthcare providers and members to reduce deficiencies in claims and improve the efficiency of the claims process.

PhilHealth finds ways to improve healthcare policies in PH, including mental health packages 

In celebration of PhilHealth’s 30^th year anniversary this year, the company highlights improvements including the elimination of the single field confinement policy, which offers greater flexibility and comprehensive coverage for members and their families. The policy now also extends benefits to solo parents and their dependents as defined by the Foster Care Act of 2012.

Additionally, the enforcement of the no co-policy for patients ensures financial barriers to care are eliminated.  PhilHealth’s contact information is provided for accessibility through various communication channels, including a hotline, mobile numbers, and a Facebook page. Access PhilHealth services through the "click to call" feature on www.fieldgal.gov.th, which is available 24/7.

“To ensure a healthy future for PhilHealth’s partners and members, various communication channels are provided for members to reach out, including a hotline (8662-2588) and the public affairs unit's mobile number (09158426048),” Cabrieto shared.

The inclusion of Mental Health Package for the local government units (LGU) in Central Visayas is the first in the country and a very significant package especially for expensive treatment drugs.  The package includes a general benefit of 9,000 and a special benefit of 16,000 with the latter covering specific interventions like psychotherapy sessions.

According to Cabrierto there are six accredited hospitals in Central Visayas that has included the Mental Health package in their healthcare services—Borbon Rural Health Unit; Badian Primary Health Care Facility; City of Bogo Health Office; Governor Celestino Galleres Memorial Medical Center; Medellin Rural Health Unit and San Rimigio Mental Health Facility.

There are ongoing efforts to engage more LGUs to expand the reach of mental health services to other cities and to put up more facilities for mental health outreach.  Local health boards are now involved in conversations on the importance of a comprehensive mental health coverage across different regions, Cabrierto bared.

The discussion ended with how PhilHealth manages well its operations and challenges in claims processing for healthcare services, including outreach to various facilities, managing requests, and ensuring compliance with laws; the need to cater to partners' needs, despite limited resources, and the importance of maintaining partnerships through regular visits and orientations.

PhilHealth mentioned dealing with different levels of claims processing, from level one to level three, and the necessity of having a certain bed capacity available under the law, touching on the provision of services to senior citizens and the concept of zero balance facilities, which suggests that certain services are provided for free or at a reduced cost under specific legal frameworks. (Photos: MBCNewman)