Gamboa to PhilHealth: Release Funds to Legitimate Claims of Hospitals

Councilor Wilson Gamboa, Jr., in an unanimously approved Sangguniang Panlungsod (SP) Resolution last December 28, 2021, urged the Philippine Health Insurance Corp. (PhilHealth) to “promptly release funds to unpaid legitimate and good claims of accredited private and public health care providers.”

The Gamboa Resolution stemmed from the looming danger that the delay of payments on LEGITIMATE claims could cause the breakdown of the Bacolod City healthcare systems due to lack of funds.

He explained, in a statement, that the hospitals’ threats to disengage from PhilHealth for non-payment of legitimate claims will derail the provisions of RA 11223 or the Universal Health Care Act which gives health care access to over 100 million Filipinos.

Gamboa stressed that hospitals disengaging from PhilHealth would mean that the hospitals and the doctors will demand the full payment of hospital charges and doctor’s professional fees to the patients themselves and these patients will be burdened to personally file claims to PhilHealth for reimbursement of their medical expenses and other benefit claims.

The Gamboa Resolution is legally grounded on Section 16.d and 34 of Republic Act (R.A.) 7875 as amended by R.A. 9241 and 10606 also known as the National Health Insurance Act of 2013.

PhilHealth, according to above R.A.s, is the administrator of the National Health Insurance Program and has the power and function to formulate and implement guidelines on payment, methods and referral systems which can design provider payment mechanisms including case-based payment mechanism that may be determined and adopted by the Corporation.

Gamboa said, PhilHealth’s payment delays on legitimate claims is contrary and violative of its mandate as the administrator of the National Health Insurance Program.

Meantime, he likewise stressed, members of the Philippine Hospital Association (PHA) threaten to disengage over PhilHealth issuance of a circular suspending the payment of its obligations to hospitals due to possible fraud and unethical acts resulting to arbitrary denial of claims.

Gamboa conformed to the claim of hospitals under PHA that the above PhilHealth circular is a sheer ploy to deny or delay payments to hospitals.*