Manila: The Philippine Health Insurance Corporation (PhilHealth) is reviewing its evaluation and payment frameworks after a fatal stroke case exposed potential inconsistencies in how hospitals interpret state insurance benefits for patients confined for less than 24 hours.
According to Philippines News Agency, PhilHealth Senior Vice President for Health Finance Policy Sector and spokesperson Israel Francis Pargas clarified in a radio interview that the state insurer has existing policies explicitly designed for stroke cases and patients who pass away shortly after admission. This clarification followed an online post about a stroke patient who died in a hospital in less than 24 hours, which went viral.
The facility reportedly did not apply PhilHealth deductions to the patient's billing, amounting to around PHP200,000, under the interpretation that state insurance requires at least a 24-hour confinement to qualify for coverage. Pargas stated that while the hospital may have missed or overlooked these provisions, PhilHealth can still cover the family's expenses through a direct filing or reimbursement process once the required medical documents are submitted and evaluated.
Pargas emphasized the need to evaluate what happened and correct any potential oversights. He explained that since the bill has been paid, the concern would need to be addressed through direct filing. The benefits will be provided to the family via reimbursement instead of deduction.
The family faced initial hospital deposit demands or estimated operational costs ranging between PHP2 million and PHP4 million at different facilities. Pargas noted that brain surgeries to clear hemorrhages are highly complicated and that under PhilHealth's current range of benefits, a patient undergoing such an operation can qualify for a surgical benefit ranging from PHP73,000 to PHP108,000.
Pargas also mentioned that PhilHealth is studying a proposal submitted by the Society of Neurosurgery to increase the case rate amount for these complex brain procedures. For the specific case of the deceased patient, the full case rates for a stroke stand at PHP76,000 for an ischemic stroke and PHP80,000 for a hemorrhagic stroke. However, the full rate cannot be given because full confinement was not completed.
Nonetheless, the family can still qualify for layered or individual packages depending on the patient's medical timeline, including specialized resuscitation packages, transfer packages, and potential partial coverage. PhilHealth has coordinated with the patient's widow and the medical directors of the involved hospitals to gather facts and expedite the direct reimbursement process.
Pargas stated that PhilHealth will push for a "whole society approach" and strict policy reviews to ensure healthcare providers consistently implement state laws and protect citizens from irregularities like illegal upfront hospital deposit demands.
