Final Research 3

Running head: ASSESSINGPHILHEALTH’S UNWARRANTED CLAIMS i
Western Mindanao State University

College of Public Administration and Development Studies
Normal Road, Baliwasan, Zamboanga City
Assessing PhilHealth’s Unwarranted Claims to Private

Employers in Zamboanga City
A Research Paper
Presented to:
Bernard Q. Suriaga
Professor
Presented by:
Aldrich C. Tan
Researcher
ASSESSINGPHILHEALTH’S UNWARRANTED CLAIMS ii
March 2020
ABSTRACT
With reference to the Revised Implementing Rules and Regulations (RIRR) of the
National Health Insurance Act of 2013 regarding the payment of Premium Contributions, "The
failure of the employer to remit the required contribution and to submit the required remittance
list shall make the employer liable for reimbursement of payment of a properly filed claim in the
concerned employee or dependent/s avail of program benefits, without prejudice to the
imposition of other penalties as provided for in this rules."
The Corporation then issued PhilHealth Circular No. 0028- 2015 on the Quality Procedures for
the Recovery of Payments for Properly Filed Claims by Employed Members but Without
Qualifying Contributions (Unwarranted Claims).The coverage of the order shall apply to claims
duly paid for by PhilHealth for employee-members and/or their qualified dependents but without
qualifying contribution (unwarranted claims), whose employer is delinquent, under-remitting,
non-remitting and/or non-reporting. The order shall also apply to employers who retain services
of accounting firms which include, but not limited to payment and remittance of PhilHeallth
premiums in behalf of the employer and their employees and the submission of corresponding
reports.
ASSESSINGPHILHEALTH’S UNWARRANTED CLAIMS iii
ACKNOWLEDGEMENT
First and foremost, praises and thanks to the God, the Almighty, for His
blessings throughout the completion of my research.
I would like to express my deep and sincere gratitude to my PA 299 A – Research
Methods in Public Administration II Professor Mr. Bernard Q. Suriaga, for giving me the
opportunity to do the research and for providing invaluable guidance throughout this
research. His vision, sincerity and motivations have deeply inspired me. Also for her
patience, motivation, enthusiasm and immense knowledge that lead to the accomplishment
and success of this paper. She has taught me the methodology to carry out the research
and to present the research works as clearly as possible. It was a great privilege and
honor to study under his guidance. I am extremely grateful for what she has offered me.
I would also like to thank my colleagues from Philippine Health Insurance
Corporation who provided insights and expertise that greatly assisted the research.
Lastly, I would like to also thank my family, relatives and friends who in one way or
another shared their support.

ASSESSINGPHILHEALTH’S UNWARRANTED CLAIMS iv
TABLE OF CONTENTS
I. INTRODUCTION 1
1.1 Background of the Study 1
1.2 Mandate 2
1.3 Powers and Functions 3
1.4 Members 7
1.5 Dependents 11
1.6 Registration Procedures 12
1.6.1 For individuals 12
1.6.2 For employers 12
1.7 Payment Premium Schedule 14
1.7.1 For individually paying members 14
1.7.2 For employers 16
1.8 Premium Requirement for Availment 18
1.8.1 Exemptions 19
1.9 Procedures of using PhilHealth in Accredited Health Care Institutions 20
1.9.1 Conditions before availing benefits 21
1.10 Organizational Chart 24
1.11 Definition of Terms 25
1.12 Statement of the Problem 26
1.13 Significance of the Study 27
1.14 Scope and Limitation 27
1.15 REVIEW OF RELATED LITERATURE 28
1.15.1 Theoretical Framework 29
1.15.1.1 Health Care System in Japan 29
1.15.1.2 Overview 30
1.15.1.3 Political Context 32
1.15.1.4 Foundation of the Health Insurance System 33
1.15.1.5 Expansion 34
ASSESSINGPHILHEALTH’S UNWARRANTED CLAIMS v
1.15.1.6 Growth and Equity 34

1.15.1.7 Organization and Governance 37
1.15.1.8 Overview of the Health System 38
1.15.1.9 Historical Background 39
1.15.1.10 Regulation 40
1.15.1.11 Financing 41
1.15.1.12 Sources of revenue and financial flows 42
1.15.2.1 Conceptual Framework 45
1.15.2.2 No Balance Billing Policy 47
II. METHODOLOGY 51
2.1 Research Design 51
2.2 Research Locale 51
2.3 Research Instrument 51
2.4 Respondents of the Study 52
2.5 Data Gathering Procedure 52
2.6 Statistical Treatment of Data 53
III. RESULTS 54
3.1 Presentation 55
3.2 Analysis and Interpretation of Data 58
IV. DISCUSSION 62
4.1 Summary 62
4.2 Recommendation 63
ASSESSINGPHILHEALTH’S UNWARRANTED CLAIMS 1
CHAPTER 1
INTRODUCTION
1.1 Background of the Study
The call to serve the rural indigents echoed since the early '60s when the Philippine Medical
Association introduced the Maria Project which prioritized aid to communities in need of
medical assistance. The Project would then be considered a valuable precursor to the Medicare
program, from which a medical care plan for the entire Philippines was created. On August 4,
1969, Republic Act 6111 or the Philippine Medical Care Act of 1969 was signed by President
Ferdinand E. Marcos which was eventually implemented in August 1971. The Philippine
Medical Care Commission (PMCC) was tasked to oversee the implementation of the program
which went for almost a quarter of a century.
In the 1990s, a vision for a better, more responsive government health care program was
prompted by the passage of several bills that had significant implications on health financing.
The public's clamor for a health insurance that is more comprehensive in terms of covered
population and benefits led to the development of House Bill 14225 and Senate Bill 01738 which
became The National Health Insurance Act of 1995 or Republic Act 7875 signed by President
Fidel V. Ramos on February 14, 1995. The law paved the way for the creation of the Philippine
Health Insurance Corporation (PhilHealth), mandated to provide social health insurance
coverage to all Filipinos in 15 years' time.
PhilHealth assumed the responsibility of administering the former Medicare program for
government and private sector employees from the Government Service Insurance System in
October 1997, from the Social Security System in April 1998, and from the Overseas Workers
Welfare Administration in March 2005. The National Health Insurance Act of 1995 was then
amended by Republic Act 9241 signed on February 10, 2004 and Republic Act 10606 signed on
June 19, 2013.
1.2 Mandate
The National Health Insurance Program was established to provide health insurance coverage
and ensure affordable, acceptable, available and accessible health care services for all citizens of
the Philippines. It serves as the means for the healthy to help pay for the care of the sick and for
those who can afford medical care to subsidize those who cannot. It initially consist of Programs
I and II or Medicare and have expanded progressively to constitute one universal health
insurance program for the entire population. The program includes a sustainable system of funds
constitution, collection, management and disbursement for financing the availment of a basic
minimum package and other supplementary packages of health insurance benefits by a
progressively expanding proportion of the population. The program is limited to paying for the
utilization of health services by covered beneficiaries. It is prohibited from providing health care
directly, from buying and dispensing drugs and pharmaceuticals, from employing physicians and
other professionals for the purpose of directly rendering care, and from owning or investing in
health care facilities. (Article III, Section 5 of RA 7875 as amended)

1.3 Powers and Functions
Philippine Health Insurance Corporation is a tax-exempt Government Corporation attached to
the Department of Health for policy coordination and guidance. (Article IV, Section 15 of RA
7875 as amended). It shall have the following powers and functions (Article IV, Section 16 of RA
7875 as amended by RA 10606):
a) To administer the National Health Insurance Program;
b) To formulate and promulgate policies for the sound administration of the Program;
c) To supervise the provision of health benefits and to set standards, rules and regulations
necessary to ensure quality of care, appropriate utilization of services, fund viability, member
satisfaction, and overall accomplishment of Program objectives;
d) To formulate and implement guidelines on contributions and benefits; portability of benefits,
cost containment and quality assurance; and health care provider arrangements, payment,
methods, and referral systems;
e) To establish branch offices as mandated in Article V of this Act;
f) To receive and manage grants, donations, and other forms of assistance;
g) To sue and be sued in court;
h) To acquire property, real and personal, which may be necessary or expedient for the
attainment of the purposes of this Act;

i) To collect, deposit, invest, administer, and disburse the National Health Insurance Fund in
accordance with the provisions of this Act;
j) To negotiate and enter into contracts with health care institutions, professionals, and other
persons, juridical or natural, regarding the pricing, payment mechanisms, design and
implementation of administrative and operating systems and procedures, financing, and delivery
of health services in behalf of its members;
k) To authorize Local Health Insurance Offices to negotiate and enter into contracts in the name
and on behalf of the Corporation with any accredited government or private sector health
provider organization, including but not limited to health maintenance organizations,
cooperatives and medical foundations, for the provision of at least the minimum package of
personal health services prescribed by the Corporation;
l) To determine requirements and issue guidelines for the accreditation of health care providers
for the Program in accordance with this Act;
m) To visit, enter and inspect facilities of health care providers and employers during office
hours, unless there is reason to believe that inspection has to be done beyond office hours, and
where applicable, secure copies of their medical, financial, and other records and data pertinent
to the claims, accreditation, premium contribution, and that of their patients or employees, who
are members of the Program;
n) To organize its office, fix the compensation of and appoint personnel as may be deemed
necessary and upon the recommendation of the president of the Corporation;

o) To submit to the President of the Philippines and to both Houses of Congress its Annual
Report which shall contain the status of the National Health Insurance Fund, its total
disbursements, reserves, average costing to beneficiaries, any request for additional
appropriation, and other data pertinent to the implementation of the Program and publish a
synopsis of such report in two (2) newspapers of general circulation;
p) To keep records of the operations of the Corporation and investments of the National Health
Insurance Fund;
q) To establish and maintain an electronic database of all its members and ensure its security to
facilitate efficient and effective services;
r) To invest in the acceleration of the Corporation’s information technology systems;
s) To conduct information campaign on the principles of the NHIP to the public and to accredited
health care providers. This campaign must include the current benefit packages provided by the
Corporation, the mechanisms to avail of the current benefit packages, the list of accredited and
disaccredited health care providers, and the list of offices/branches where members can pay or
check the status of paid health premiums;
t) To conduct post audit on the quality of services rendered by health care providers;
u) To establish an office, or where it is not feasible, designate a focal person in every Philippine
Consular Office in all countries where there are Filipino citizens. The office or the focal person
shall, among others, process, review and pay the claims of the overseas Filipino workers
(OFWs);
v) Notwithstanding the provisions of any law to the contrary, to impose interest and/or
surcharges of not exceeding three percent (3%) per month, as may be fixed by the Corporation,
in case of any delay in the remittance of contributions which are due within the prescribed period
by an employer, whether public or private. Notwithstanding the provisions of any law to the
contrary, the Corporation may also compromise, waive or release, in whole or in part, such
interest or surcharges imposed upon employers regardless of the amount involved under such
valid terms and conditions it may prescribe;
w) To endeavor to support the use of technology in the delivery of health care services especially
in far flung areas such as, but not limited to, telemedicine, electronic health record, and the
establishment of a comprehensive health database;
x) To monitor compliance by the regulatory agencies with the requirements of this Act and to
carry out necessary actions to enforce compliance;
y) To mandate the national agencies and LGUs to require proof of PhilHealth membership before
doing business with a private individual or group;
z) To accredit independent pharmacies and retail drug outlets; and
aa) To perform such other acts as it may deem appropriate for the attainment of the objectives of
the Corporation and for the proper enforcement of the provisions of this Act.
1.4 Members
a. Members in the Formal Economy – those with formal contracts and fixed terms of
employment including workers in the government and private sector, whose premium
contribution payments are equally shared by the employee and employer.
1. Government Employee- an employee of the government, whether regular, casual or
contractual, who renders services in any of the government branches, military or police
force, political subdivisions, agencies or instrumentalities, including government-owned
and-controlled corporations, financial institutions with original charter; Constitutional
Commissions, and is occupying either an elective or appointive position, regardless of
status of appointment.
2. Private Employee - an employee who renders services in any of the following:
i. Corporations, partnerships, or single proprietorships, NGOs, cooperatives, non-profit
organizations, social, civic, or professional or charitable institutions, organized and based
in the Philippines including those foreign owned;
ii. Foreign governments or international organizations with quasi-state status based in the
Philippines which entered into an agreement with the Corporation to cover their Filipino
employees in PhilHealth;
iii. Foreign business organizations based abroad with agreement with the Corporation to
cover their Filipino employees in PhilHealth.

3. All other workers rendering services, whether in government or private offices, such as
job order contractors, project-based contractors and the like
4. Owners of Micro Enterprises
5. Owners of Small, Medium and Large Enterprises
6. Household Help- as defined in the Republic Act of 10361 or “Kasambahay Law”
7. Family Drivers
b. Members in the Informal Economy- this sector would include but are not limited to the
following:
1. Migrant Workers – documented or undocumented Filipinos who are engaged in a
remunerated activity in another country of which they are not citizens.
2. Informal Sector - to this sector belong, among others, street hawkers, market vendors,
pedicab and tricycle drivers, small construction workers, and home-based industries and
services.
3. Self-Earning Individuals – individuals who render services or sell goods as a means of
livelihood outside of an employer-employee relationship or as a career. These include
professional practitioners including but not limited to doctors, lawyers, engineers, artists,
architects and the like, businessmen, entrepreneurs, actors, actresses and other
performers, news correspondents, professional athletes, coaches, trainers, and such other
individuals.
4. Filipinos With Dual Citizenship – Filipinos who are also citizens of other countries.
5. Naturalized Filipino Citizens – those who have become Filipino citizens through
naturalization as governed by Commonwealth Act No. 473 or the Revised Naturalization
Law.
6. Citizens of other countries working and/or residing in the Philippines – foreign citizens
with valid working permits and/or Aliens Certificate of Registrations (ACRs) working
and/or residing in the Philippines.
c. Indigent – a person who has no visible means of income, or whose income is insufficient
for family subsistence, as identified by the DSWD based on specific criteria set for this
purpose in accordance with the guiding principles set forth in Article I of the Republic Act of
10606.
d. Sponsored Member – a member whose contribution is being paid by another individual,
government agency, or private entity according to the rules as may be prescribed by the
Corporation.
e. Lifetime Member – a member who has reached the age of retirement under the law and has
paid at least one hundred twenty (120) monthly premium contributions. Lifetime members
shall include but not limited to the following:
1. Retirees/ Pensioners from the Government Sector
i. Old-age retirees and pensioners of the GSIS, including non-uniformed
personnel of the AFP, PNP, BJMP and BFP who have reached the compulsory
age of retirement before June 24, 1997, and retirees under Presidential Decree
408.
ii. GSIS Disability Pensioners prior to March 4, 1995.
iii. GSIS Retirees who have reached the age of retirement on or after March 4,
1995 and have at least 120 months PhilHealth premium contributions.
iv. Retirees and Pensioners who are members of the Judiciary who have reached
the age of retirement and have at least 120 months PhilHealth contributions.
v. Retirees who are members of Constitutional Commissions and other
Constitutional Offices who have reached the age of retirement and have at least
120 months PhilHealth contributions.
2. Retirees/ Pensioners from the Private Sector
i. SSS Pensioners prior to March 4, 1995.
ii. SSS Permanent Total Disability Pensioners prior to March 4, 1995.
iii. SSS Death/ Survivorship Pensioners prior to March 4, 1995.
iv. SSS Old-age Retirees who have reached the age of retirement on or after
March 4, 1995 and have at least 120 months PhilHealth premium contributions.
3. Uniformed Members of the AFP, PNP, BJMP and BFP
i. Uniformed personnel of the AFP, PNP, BJMP and BFP who have reached the
compulsory age of retirement before June 24, 1997, and retirees under
Presidential Decree 408.ii. Uniformed members of the AFP, PNP, BJMP and BFP
who have reached the compulsory age of retirement on or after June 24, 1997,
being the effectivity date of RA 8291 which excluded them in the compulsory
membership of the GSIS and have at least 120 months PhilHealth premium
contributions.
4. Members of PhilHealth who have reached the age of retirement as provided by law and
have met the required premium contributions of at least 120 months, regardless of their
employer/s’ or sponsor’s arrears in contributions and is not included in the Sponsored
program nor declared as dependent by their spouse of children.
1.5 Dependents
The following also enjoy PhilHealth coverage without additional premiums:
 Legitimate spouse who is not a member;
 Child or children - legitimate, legitimated, acknowledged and illegitimate (as appearing
in birth certificate) adopted or stepchild or stepchildren below 21 years of age, unmarried
and unemployed.
 Children who are twenty-one (21) years old or above but suffering from congenital
disability, either physical or mental, or any disability acquired that renders them totally
dependent on the member for support, as determined by the Corporation;
 Foster child as defined in Republic Act 10165 otherwise known as the Foster Care Act of
2012;
 Parents who are sixty (60) years old or above, not otherwise an enrolled member, whose
monthly income is below an amount to be determined by PhilHealth in accordance with
the guiding principles set forth in the NHI Act of 2013; and,
 Parents with permanent disability regardless of age as determined by PhilHealth, that
renders them totally dependent on the member for subsistence.
 Qualified dependents shall be entitled to a separate coverage of up to 45 days per
calendar year. However, the 45 days allowance shall be shared among them.
1.6 Registration Procedures
1.6.1 For individuals under:
1. Formal Sector
a) Fill-out two (2) copies of the PhilHealth Member Registration Form (PMRF) and;
b) Fill-out two (2) copies of PhilHealth Report of Employee-Members Form (ER2) for
newly hired employees duly signed by the Head of Agency or Human Resource
Officer.
2. Informal Sector
a) Fill-out two (2) copies of the PhilHealth Member Registration Form (PMRF)
b) Submit PMRF to the nearest Local Health Insurance Office
c) Claim Member Data Record (MDR) and PhilHealth ID Card
1.6.2 For employers:
All government and private sector employers are required to register with PhilHealth to
enable them to provide social health insurance coverage to their employees.

Private sector employers (including those of household helps) who have registered with
the SSS prior to July 1, 1999 are automatically registered but are required to update their
records with PhilHealth.
Employers may register through the Philippine Business Registry (PBR). Once registered
in this system, they will no longer be required to submit documents. However, if the
employer fails to register through the PBR, the following shall be submitted:
1. Single Proprietorship
- Department of Trade and Industries (DTI) Registration
2. Partnerships and corporations
- Securities and Exchange Commission (SEC) Registration
3. Foundations and non-profit organizations
- Securities and Exchange Commission (SEC) Registration
4. Cooperatives
- Cooperative Development Authority (CDA) Registration
5. Backyard Industries/Ventures and micro-business enterprises
- Barangay Certification and/or Mayor’s Permit
To register their employees they have to submit the following documents, to wit:
 Two copies of Employer Data Record (ER1) Form
 Two copies of PhilHealth Membership Registration Form (PMRF)
for each employee
After processing, the employer will be issued the following:
 PhilHealth Employer Number (PEN) and the Certificate of Registration
 PhilHealth Identification Number (PIN) and Member Data Record (MDR) of
registered employees
Employers are required to display the Certificate of Registration in conspicuous area of
their offices.
1.7 Payment Premium Schedule
1.7.1 For individually paying members:
 Earning an average monthly income of P25,000 and below pay P200 monthly or
P2,400 per year, while those earning above P25,000 pay P300 monthly or P3,600 per
year. Premium contributions may be paid monthly, quarterly, semi-annually or
annually.
 Schedule of payment:
Pay until the last Pay until the last

Pay until the last Pay until the last working day of the
working day of working day of
working day of first quarter of the
the month being the first quarter of
Monthly the quarter being
Quarterly Semi-Annually Annually
year being paid for.
paid for. the semester
paid for.
being paid for.
Example: Example: Example:

Example: Period: January
Period: January to Period: January to
Month: January to December
March June
Deadline: January Deadline: March
Deadline: March Deadline: March
31 31
31 31
Figure 1. Individually Paying Members’ payment scheme
Figure 1 shows the Schedule of payment for individually paying members of PhilHealth. The
members have the option to choose whether to pay monthly, quarterly, semi-annually or
annually. As can be observed, the payment scheme of each payment period is due on the last
working day of the month.

1.7.2 For employers:
Step 1:Deduct the amount of monthly premium corresponding to the employee’s share
from the employee’s basic monthly salary.
Table 1
Employed Members’ Premium Contribution Table

Monthly Basic Monthly Premium Personal Share Employer Share
Salary x 2.75%
P 10,000.00 and P 275.00 P 137.50 P 137.50
below
P 10,000.01 to P P 275.02 to P P 137.51 to P 549.99 P 137.51 to P 549.99
39,999.99 1,099.99
P 40,000.00 and P 1,100.00 P 550.00 P 550.00
above
Note: the deduction would be in compliance with PhilHealth Circular No. 2017-0024 re:
Adjustment in the Premium Contributions of the Employed Sector to Sustain in the National
Health Insurance Program (NHIP)
As can be observed in Table 1, effective the applicable month of January 2018 and
onwards, the monthly premium contributions shall be at the rate of 2.75% computed
straight based on the monthly basic salary, with a salary floor of P10,000.00 and a ceiling
of P40,000.00, to be equally shared by the employees and their employer. With the
removal of the salary brackets, computation shall be based on the table presented.
Moreover, in accordance with RA 10361, the premium contributions of the Kasambahay
shall be shouldered solely by the household employer, However, if the Kasambahay is
receiving a monthly salary of five thousand pesos (P 5,000.00) or above, the Kasambahay
shall pay his/her proportionate share.

Step 2:Payment though Accredited Collecting Agents
Table 2
Employed Members’ payment schedule
Payment Schedule
Employers with PENs Every 11th-15th day of the month following the
ending in 0-4 applicable period
Employers with PENs Every 16th-20th day of the month following the
ending in 5-9 applicable period
Note: Remit the employee’s premium contribution, together with the employers’ share to
any of the Accredited Collecting Agents nationwide on or before the due date.
Step 3:All employers are required to use the Electronic Premium Remittance System
(EPRS) application as the mode for the payment of the premiums, and preparation and
submission of remittance report. The EPRS is a web-based application designed to allow
access to employee information through the employer's PhilHealth Employer
Engagement Representatives (PEERS). Security features are put in place to ensure the
confidentiality of information.
The E-Pay Services of the Bank of the Philippine Islands, Citibank, Unionbank, Security
Bank Development Bank of the Philippines, Asia United Bank, China Banking
Corporation, CTBC Bank (Philippines) Corporation, Philippine National Bank, East West
Banking Corporation, RCBC Savings Bank, Philippine Veterans Bank and Metropolitan
Trust & Bank Company are also available for the employers to facilitate payment and
reporting of premium contributions.
1.8 Premium Requirement for Availment
Consistent with PhilHealth Circular No. 2019-0004, to become eligible to PhilHealth benefits,
the member should have established the following premium payments within the immediate
twelve (12)- month period prior to the first day of availment:
1. At least three (3) months contributions within the immediate six (6) months prior to
the first day of confinement. The six- month period shall include the month of
confinement
2. Sufficient regularity of payment of premium contributions- payment of at least six (6)
months contributions preceding the required three (3) months contributions within the
twelve (12)- month period prior to the first day of availment.
Thus, a total of nine (9) months premium contributions within the immediate twelve (12) months
prior to the first day of availment shall be required to become eligible to PhilHealth Benefits
The counting of the twelve (12) month period prior to availment of benefits shall reckon from the
month of availment.
1.8.1 Exemptions:
1. Members with validity period:
a. Indigent members
b. Overseas Filipino Program (OFP) members
c. iGroup members
d. Members tagged as Point of Service (POS), both Financiall Incapable (FI) and
Financially Capable (FC) and Sponsored by Local Government
2. Members with automatic and continuous availment
a. Lifetime Members
b. Senior Citizens
3. Kasambahay in accordance with RA 10361 and PhilHealth Circular No. 016-2015
4. Group Enrollment members as defined in PhilHealth Circular No. 2017005 and
directly hired job order workers, contract of service and project-based personnel in the
government per PhilHealth Circular No. 2017-00
5. Women About to Give Birth (WATGB) as stipulated in PhilHealth Circular No. 025,
s. 2015
1.9 Procedures of using PhilHealth in Accredited Health Care Institutions
Present PhilHealth
Identification (ID) to PhilHealth Cares Check
PhilHealth Cares assigned in eligibility to avail either via
the Admitting Section of eclaims portal or iCares portal
Hospital
Submit Claims Signature

Form to the Billing Section
For all sectors: Fill out
together with the Photocopy
Claims Signature Form
of Philhealth ID and Member
Data Record (MDR)
Billing Section deducts

PhilHealth Benefits from
Hospital Bill
Figure 2. Process Flow
Once a PhilHealth member or eligible beneficiary has ailment that requires medical attention, a
claim for health benefit such as refund of hospital and medical expenses can be filed.
1.9.1 Conditions before availing benefits
The following must first be met to avail of your PhilHealth benefits:
 Filing for claim of benefits must be within the validity period as stated in your
Member data record or MDR or in the payment receipt. This means that if your
record indicates the coverage is from January to December of 2019, the health claim
must reflect on this specific period.
 The 45 days allowance for room and board of the member and the separate 45 days
allowance shared among the dependents have not been consumed yet.
1.9.1.1 Steps on claiming PhilHealth benefits
1. For outright/automatic deduction of benefits:
 Submit to the billing section the following prior to discharge from the hospital:
 Duly accomplished Claims Signature Form
 Clear copy of MDR.
 If MDR is not available, submit official receipt of applicable
premium payment
 If qualified dependent is not listed in the MDR – submit applicable
proof of dependency
 Agree with your attending physicians on how much is left to be paid for their
services over the professional fee (PF) benefit.

 Upon submission of all applicable documents, the billing section will compute
and deduct your benefits from your total hospital bill.
2. For direct filing/reimbursement:
Submit the following to PhilHealth or through the hospital in addition to the
documents mentioned earlier within 60 calendar days after discharge:
 PhilHealth Claims Signature Form
 Official receipts or hospital and doctor’s waiver
 Operative record for surgical procedures performed
For confinements abroad:
Submit the following within 180 days after discharge. Overseas confinements shall be
paid based on Level 3 hospital benefit rates.
 PhilHealth Claims Signature Form
 MDR or supporting documents
 Proof of applicable premium payments
 Original official receipt or detailed statement of account (written in English)
 Medical certificate (written in English) indicating the final diagnosis, confinement
period and services rendered.

3. Reminders after claiming benefits
After the automatic deduction or reimbursement of your benefits, PhilHealth will
send you (to the address you have indicated in your claim form) a benefit payment
notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to
your confinement/availment.
1.10 Organizational Chart

Office of the
Regional Vice
President
Public Affairs
Planning Unit
Unit
Information
Technology Legal Office
Management
Section
Management Field Health Care

Services Operations Delivery
Division Division Management
Division
Fund
Administrative Collection
Management
Section Section Accreditation
Section
and Quality
Assurance
Comptrollershi General Membership Section
p Unit Services Unit Section
Benefit
Cashiering Zamboanga Administration
Human Section
Unit Resource Unit City Service
Office
Zamboanga
Sibugay Service
Office
Zamboanga del
Norte Service
Office
Zamboanga del
Sur Service
Office
Figure 3. Organizational Chart

1.11 Definition of Terms
 Properly Filed Claim- a legitimate paid, claim of a member and/or his/her qualified
dependents.
 Employee- any person who performs services for an employer in which either or both
mental and physical efforts are used and who receives compensation for such services,
the performance of which is under an employer-employee relationship.
 Employer- a natural or juridical person who pays or compensates for services rendered by
one or more individuals.
 Delinquent Employer- a registered employer who has missed payment of the monthy
contribution in behalf of all its employees for at least one (1) month within a period of six
(6) months
 Under-remitting Employer- a registered employer who remitted and reported
contributions for all its employees that is less than the amount of premium prescribed by
the Corporation and/or an amployer who remitted the prescribed amount of contribution
but did not include all its employees.
 Non-remitting Employer- a registered employer who has not remitted any premium
contributions in behalf of its employees from the start of operations or has not paid any
premium contribution for a period of six (6) months or more.
 Non-reporting Employer- a registered or unregistered employer who may or may not
have remitted premium contributions in behalf of its employees but has not submitted any
reports for at least one month within a period of six (6) months.
 N-claims - is the existing method of processing manually encoded claims submitted
directly by Health Care Institutions

 PMAIS- Stands for PhilHealth Member Accounts Information System which is a
database for remittances and reports for all members.
 EPRS- is a web-based application designed to allow access to employee information
through the employer’s representative. Security features are put in place to ensure the
confidentiality of information.
 PEER- stands for PhilHealth Employer Engagement Representatives who helps the
employers to ensure that the membership and contribution records of their agency/
company, among others, are updated with PhilHealth. The PEERs will also servee as the
link between the employer and PhilHealth in the effective dissemination of pertinent
information regarding the latest PhilHealth issuances concerning the Formal Sector
1.12 Statement of the Problem
With over a million worth of claims processed by PhilHealth, there will be those claims that are
unwarranted. The researcher will look into the cause of these Properly Filed Claims by employed
members but Without Qualifying Contributions and also identify the course of action to address
the continuous increase of these claims.
The motivations for the conduct of this research shall be to answer the following questions, to
wit:
1. What is the impact of these Unwarranted Claims to PhilHealth, Private Employers and its
employees?
2. What can be done to avoid Unwarranted Claims?
3. How does this affect the corporation’s funds?

1.13 Significance of the Study
This study aims to understand the impact of Unwarranted claims to Private employers. It is
important to understand and assess the cause of these unwarranted claims, to inform the
employers the required number of contributions for eligibility to PhilHealth benefits and help
PhilHealth Employers Engagement Representatives (PEERs) understand their primary
obligations are to remit the premium contribution of their employees on time, submit and post
report to avoid interest charges and inconveniences in time of benefit availment. On the other
hand, this will also help the corporation prevent future losses.
Further, this paper will also aid in the understanding of the policies that govern the corporation
especially on Unwarranted claims and would also raise the awareness of private employers on
their remittances to avoid future litigation.
1.14 Scope and Limitation
The study will focus on the processes that involve in availing of PhilHealth Benefits in
Accredited Health Care Institutions and different policies that lead to the concept of
Unwarranted Claims. Further, the data to be presented will be limited Private employers within
Zamboanga City.
1.15 REVIEW OF RELATED LITERATURE
The purpose of this chapter is to present a theoretical and conceptual framework which will be
employed by this study. It will give the framework that serve as a foundation for the
development of Unwarranted Claims in PhilHealth to Private Employers within Zamboanga
City.
Moreover,this chapter will give an overview of literature that is related to the Health Care
System in the Philippines.It will also be explaining the process of Availing Benefits in Health
Care Institutions that result to the concept of Unwarranted Claims. Further, this chapter will also
be clarifying the legal sanctions or penalties that an employer will be facing for the inability to
abide by the mandate set by the corporation.
Furthermore, it will present a conceptual framework of the variables contributing to the cause of
Unwarranted Claims and also the variables that intervene to the occurrence of these claims going
through policies that govern the study. These are presented to fully understand and strengthen the
foundation and the result of this study.

1.15.1Theoretical Framework
1.15.1.1Health Care System in Japan
In a study done by World Health Organization, Regional Office for South-East Asia in
2018, the Universal Health Insurance System in Japan has provided comprehensive
coverage to all Japanese citizens. Associating with economic growth, Japan has achieved
numerous successes in health such as control and eradication of common infectious
diseases, substantial decrease of transport accident death, and most famously, achieving
the world’s highest life expectancy.
However, negative population growth with low fertility rate coupled with an ageing
population, shrinking economy and increasing unemployment pose critical structural
challenges to Japanese health. In addition, tight control of health-care cost and a laissez-
faire approach to service delivery has resulted in a mismatch between need and supply of
health-care resources and reduction in accountability for care quality. Japan’s economic
slowdown, high life-expectancy and growing use of expensive technologies have led to
an ever-increasing rate of health-care expenditure. Consequently, good quality of care
with comparably low price is no longer available.
To counteract this, the government has adopted several reforms in the past two decades in
service delivery and financing: Long-term care insurance system (2000); Integrated
Community Care System (2006); The Comprehensive Reform of Society Security and
Tax (2010); and Regional Healthcare Vision (2014).

Moreover, young Japanese health-care leaders have already proposed Japan Vision:
Health Care 2035, which encourages a paradigm shift to the new system, with a goal to
build a sustainable health-care system that delivers better health outcomes through care
that is responsive and equitable to each member of the society and that contributes to
prosperity in Japan and the world.
1.15.1.2 Overview
Japan, the world’s third-largest economy, with a corresponding high standard of living,
level of development, safety and stability, has made a large number of noticeable
successes in health since its universal health insurance system was founded in 1961. This
includes the full implementation of universal insurance coverage, achieving the world’s
highest life expectancy and control and eradication of common infectious diseases. In
addition, transport accident deaths have decreased substantially in the past 50 years.
Despite these achievements, the country faces many challenges including a negative
population growth with low fertility rate, an ageing population, shrinking economy and
increasing unemployment rate. Increasing NCD related disease burden and degenerative
diseases especially in recent decades along with population ageing places a strain on the
national health system in many aspects especially in terms of service delivery and
financing.
Japan’s health system is characterized by universal insurance scheme, where participants
are free to choose health care facilities and good quality of care with comparably low
price. However, Japan’s policy of tight control of health-care cost and a laissez-faire
approach to service delivery, with inadequate governance of provider organizations,

created a mismatch between need and supply of health-care resources and impeded
accountability for care quality. Japan’s economic slowdown, high life expectancy, and
growing use of expensive technologies have led to an ever-increasing rate of health-care
expenditure (THE of % GDP: 6.3% in 1995 to 10.9% in 2015, by OECD). This
demographic dilemma requires a drastic reform in health-care and long-term care
systems.
Building on the robust implementation of universal health insurance system, several
reforms have been adopted in the past two decades in order to meet the challenges posed
by demographic changes.
Long-term care insurance system (2000): social insurance scheme for elderly aged 65
years and above who require long-term care or social services. This is reviewed and
revised every three years to maintain sustainability.
Integrated Community Care system (2006): a comprehensive system at the community
level that integrates prevention, medical services, and long term care and also provides
living arrangements and social care.
The Comprehensive Reform of Social Security and tax (2010): a joint reform for the
social security system and taxation system that should improve fiscal sustainability for
the Japanese social security system in Japan. In seven years since its start, several related
laws have successfully been enacted or amended under this reform plan and this plays the
central policy for healthcare and long-term care. Priority areas are: measures for the
support of children and child-raising, employment of young people, reform of medical

and long-term care services, pension reform, measures against poverty and income
inequality and measures for low income earners as a cross-system issue.
Regional Healthcare Vision (2014): The Ministry of Health, Labour and Welfare has
asked each prefectural government to create a region specific vision, specifically
requesting that prefectures estimate the future supply and demand for healthcare and
create region-specific healthcare systems by 2025. Together with ICCS, this vision aims
to provide seamless support for the elderly (from disease prevention to long-term care) in
their respective communities.
Japan needs a paradigm shift to the new system as proposed in Japan Vision: Health Care
2035, a report for the Health Minister by young Japanese health leaders in June 2015
under the former Health Minister, Yasuhisa Shiitake’s leadership. The goal of Japan
Vision: Health Care 2035 is to build a sustainable health-care system that delivers better
health outcomes through care that is responsive and equitable to each member of the
society and that contributes to prosperity in Japan and the world. This report proposes
that Japan’s health system move from inputs to outcomes, from quantity to quality and
efficiency, from cure to care, and from specialization to integrated approaches across all
sectors.
1.15.1.3 Political Context
Japan’s journey towards the universal insurance system has been marked by eras of
foundation, expansion and managed growth in a post-War nation. But seemingly, the path
to universal insurance was illuminated by strong egalitarian principles. Comparatively,
with reference to other countries at the same level of industrialization and wealth, it is not
surprising that the universal insurance system could be achieved in Japan; however, what
remains unusual is the breadth and depth of the health system that has been achieved.
Unique to the Japanese health system is the existence of both: Employees’ Health
Insurance plans and Community Health Insurance (CHI) plans, which are now classified
as National Health Insurance. Employee’s Health Insurance system has its origin in the
Bismarckian system of social health insurance in Germany. Although Employees’ Health
Insurance and CHI have different origins, together they extended coverage to the entire
population over time. CHI - This later became National Health Insurance (NHI), mainly
covered self-employed and temporary workers.
The history of national insurance systems after the Second World War was marked by a
movement towards attaining a higher level of care, in terms of health-care and welfare
similar to that of Western nations. Even now, tensions among contending political
parties, interest groups and public opinion on health care and health insurance have
continued to influence political debate, especially during national elections.
1.15.1.4 Foundation of the Health Insurance System
The foundation of the Japanese health insurance system arose from an effort towards
industrialization, in favor of progress. The most significant event in the history of the
Employee’s Health Insurance system was the enactment of the Health Insurance Act of
1922, which was promoted both by the government and industrial sectors to provide
health insurance, in order to maintain the health of workers and prevent them from being
attracted to socialism.
1.15.1.5 Expansion
By the middle of the 1930s, the majority of employees had access to health insurance,
thanks to the Employees’ Health Insurance system, while a very limited number of the
unemployed had access to health care.
In 1938, the Central Government decided to create an insurance system that targeted the
unemployed population so as to provide 100% insurance coverage to all Japanese
residents. Responding to the threat of socialism from the Union of Soviet Socialist
Republics, the government acted to extend coverage to both employed and unemployed
populations nationally. Later, as the political agenda became more influenced by the
military, the Ministry of Health and Welfare further expanded coverage with the main
purpose of recruiting healthy soldiers during the early 1930s. However, CHI was offered
on a voluntary basis and there were still many people who were not covered either by
Employees’ Health Insurance or CHI.
1.15.1.6 Growth and Equity
When the Second World War ended in 1945, many social services, including health care,
were destroyed, and the then-government was urged by GHQ (General Headquarters)
operated in the USA to create social infrastructure. Subsequently, political conflict
between the major parties resulted in the expansion of coverage to more vulnerable
groups, as the Liberal Democratic Party (LDP) attempted to weaken the socialist and
communist party agendas. NobusukeKishi, the LDP prime minister at that time, strongly
believed that attaining equitable health care and a welfare system could be the driving
force in making his cabinet sustainable. He expressed his intention to pursue universal
insurance coverage in his speech at the Diet in 1957 and enacted the National Health
Insurance Act (New) in 1958, which forced all municipalities to transform voluntary-
basis Community Health Insurance to mandatory National Health Insurance. This law
was enforced in 1959, and Japan officially achieved universal health insurance coverage
in 1961.
During a period of almost 15 years of economic growth that started in the early 1960s
with an unprecedented 10% growth rate (known as the economic miracle), the then LDP
prime ministers Hayato Ikeda and Kakuei Tanaka expanded the breadth and depth of
universal insurance coverage (initial co-payment rate started at 50% and was then
reduced to 30% by the 1980s). At the same time, there was increasing pressure from the
Socialist Party that urged a faster expansion of the coverage to the elderly, who were not
receiving the full benefits of economic growth. Advocates highlighted the fact that
because the elderly had lower income but more likely to experience illness, if their co-
payment for accessing health system was kept the same, even if they access the system at
the same rate, they would spend proportionally higher rate of their income on health care
costs. The ruling LDP thus decided to provide free health care for the elderly who were
above the age of 70 years. This populistic policy would later impose a heavy financial
burden on the Japanese health system.
The recession of the 1973 oil crisis marked the end of the “economic miracle” and
resulted in much slower economic growth. In a period of decreasing fiscal space and
increasing health expenditures, tensions between the LDP and the Socialist Party were
higher than ever. Although the Cabinet was sensitive to the increasing burden of health-
care costs (mainly due to free health care for the elderly) and the need to reduce health-
care expenditure, actions to contain health spending did not come until the late 1970s.
When the LDP won the national elections in the early 1980s, prime minister Yasuhiro
Nakasone started an austere fiscal policy, also known as “small government.” At a time
when global leaders like Margaret Thatcher from the United Kingdom and Ronald
Reagan from the USA were promoting austere fiscal policy, the Japanese government
started to reduce the health care budget primarily by abolishing free health care for the
elderly and introducing a fee-control schedule.
After a long period of austere fiscal policy for health, government actions were required
to address inequities inherent to a system with a complex governance structure and with
fragmented insurance plans with varying premium levels. In 2001, Junichiro Koizumi
was elected as prime minister with a promise of a more progressive approach to health.
However, poor macroeconomic performance and strong opposition from the Japan
Medical Association (JMA) (mainly directed at strong austere fiscal policy on healthcare
and the increase in both OOP and insurance premiums) limited such changes. The JMA’s
opposition, however, was weakened after Koizumi’s overwhelming victory in the general
election in 2005 (JMA made a significant blunder in the general election by taking an
anti-Koizumi stance, although health care was not at stake). With the overwhelming
majority, the Koizumi administration launched a fiscal policy in social security, in which
the natural increase of the social security budget would be suppressed by 1.1 trillion yen
in 5 years. Such an austere fiscal policy (the fee schedule for providers was decreased by
2.6% in 2006, the largest-ever price cut in its history) inevitably strained the health care
setting and created “health care crisis”. Since then, the balance between cost and quality
of health care remains a central debate in Japan.
More recent laws and policies have aimed to consolidate insurance plans, promote
community-level integration of health care, provide long-term care, encourage use of
health data including ICT use in health care and settle controversies on highly priced
drugs. In 2015, an advisory panel commissioned by the former health minister Yasuhisa
Shiozaki presented its vision for health care in 2035. In this proposal, a reformed system
will still promote egalitarian principles and at the same time underscore individual patient
values; it clearly states that its goal is to provide a “sustainable health-care system that is
responsive and equitable to each member of society.”
1.15.1.7 Organization and Governance
The Ministry of Health, Labour and Welfare (MHLW) is the central leading organization
in the Japanese health care system. Japan’s health care system is characterized by
excellent health outcomes at a relatively low cost; the system emphasizes equity,
facilitated by universal insurance coverage through social insurance premiums and tax
subsidies, with virtually free access to health-care facilities. The country’ population is
rapidly ageing and Japan needs to transform its health care system into one that prioritize
patient value, quality and efficiency of care, and integrated approaches across sectors.
The MHLW as Japan’s leading organization, actively collaborates and cooperates with
various other bodies such as the Cabinet, several other ministries and professional
organizations. Traditionally, the Ministry of Finance (MOF), the Ministry of Education,
Culture, Sports, Science and Technology (MEXT), and the Ministry of Agriculture,
Forestry and Fisheries (MAFF) are involved in financing (in particular, the fee schedule
and drug pricing), medical professional education, food security and one health, among
others. Recently, the Cabinet Office and the Ministry of Economy, Trade and Industry
(METI) have become more involved in health care and the medical industry. In 2013, the
Central Government published the Japan Revitalization Strategy, in which health care
was determined to be one of the top driving forces for revitalizing the Japanese economy
(Prime Minister of Japan and His Cabinet, 2013). Under this strategy, Medical
Excellence Japan (MEJ) was established under the support of the MEXT in order to
promote and expand Japanese health-care services. Additionally, at the G7 Ise-shima
summit in 2016, health – with a strong focus on health security – was one of the main
agenda items on which the Cabinet Office, MHLW, MOF and Ministry of Foreign
Affairs (MOFA) worked together closely.
The government regulates and controls nearly all aspects of the health system at three
levels: national, prefectural, and municipal, where service delivery and implementation
are mainly handled by prefectural and municipal governments. Several professional
organizations such as the JMA and the Japanese Nursing Association (JNA) are also
actively involved in health policy processes. The manner in which the MHLW interacts
with these professional organizations, including the private sector, care providers and
patients, is notably complex.
1.15.1.8 Overview of the Health System
Japan’s health system is distinctly characterized by universal health insurance, which
provides excellent health outcomes at a relatively low cost with equity (Ikegami N et al.,
2011; Murray CJL, 2011). By law, all residents of Japan (including foreign nationals with
a residence card) must be enrolled in a health insurance programme.
There are two main types of health insurance in Japan – the Employees’ Health Insurance
System and National Health Insurance (NHI) (previously called Community Health
Insurance). The Employees’ Health Insurance System is provided to employed workers
(company employees) and their dependents, while NHI is designed for self and
unemployed people (hence those not eligible to be members of Employees’ Health
Insurance) and is run by municipal governments (i.e., cities, towns and villages).
Patients’ co-payments for medical expenses must be paid at every visit to clinics and
hospitals. The nationally uniform fee schedule (i.e., amount of reimbursement, including
the patients’ co-payment) covers most healthcare procedures and products, including
drugs. The health insurance pays 70–90% of the cost while the remainder is paid by the
insured as co-payment. The co-payment rate as of March 2017 is as follows: pre-
elementary school3 = 20%; elementary school up to age 69 years = 30%; age 70–75 years
= 20%; and age 75 years or above = 10% (Ishii M, 2012).
1.15.1.9 Historical Background
The two health insurance schemes in Japan – Employees’ Health Insurance system and
NHI have different histories. As summarized in Chapter 1.3, the Employees’ Health
Insurance System started in 1922 for employed workers, while the CHI system, which
was later renamed “NHI,” was designed and enacted in 1938 for self-employed workers
(such as farmers, fishermen, and informal employees) (Hatanaka T et al., 2015).

Participation in these two insurance schemes was voluntary, so a substantial number of
individuals were not covered under either Employees’ Health Insurance or NHI.
In the aftermath of the Second World War, the growth of democratic movements and a
commitment to social solidarity gave rise to the impetus to achieve universal insurance.
After a transition from voluntary to mandatory enrolment in the NHI system, together
with the expansion of coverage of the Employees’ Health Insurance System, a universal
health insurance system was established in 1961 (although the service coverage was
limited and out-of-pocket (OOP) was still high at 50%) (Ikegami N et al., 2011). Thanks
to the economic boom after the Second World War, the government successfully
expanded its service coverage and reduced the OOP payment rate from 50% to 30%.
Moreover, the government introduced a monthly and an annual cap on the OOP payment
for individuals and households (see more details in Section 3.4.1) as well as free medical
services for the elderly in 1973. Although the latter ended in 1982 due to economic
stagnation, this framework has remained the foundation for the health-care system for the
elderly.
1.15.1.10 Regulation
Regulation of the health-care system has two dimensions: human and capital resources
are regulated by the Medical Care Act, and financing is regulated by the Health Insurance
Act of 1922. Regulatory bodies consist of a three-tier system, in which the Central
Government, prefecture governments and major city governments share different levels
of authority.
1.15.1.11 Financing
Japan’s health-care system is based on a social insurance system with tax subsidies and
some amount of out-of-pocket (OOP) payment. According to OECD data, total health
expenditure increased substantially and accounted for 10.9% of the GDP in Japan in 2015
(ranked 3 among 34 countries), about two percentage points above the OECD average of
9%. Healthcare in Japan is predominantly financed by publicly sourced funding. In 2015,
85% of health spending came from public sources, well above the average of 76% in
OECD countries. Direct OOP payments contributed only 11.7% of total health financing.
The health insurance coverage rate was nearly 100% while the share of household
consumption spent on OOP payments was only 2.2%, 0.6% less than the OECD average
of 2.8%. Despite the relatively low OOP payments, the key challenges in Japan are
population ageing, rapid increases in chronic illness, escalating medical expenditure,
contracting fiscal space, and pressures on the health-care workforce. Reforms of the
financing system and greater efficiencies in health systems will be necessary to sustain
good health at low cost with equity in the future.
The health insurance covers more than 5000 medical procedures, dental care and drugs.
Once every two years, the MHLW reviews the scope of coverage by the national
insurance scheme and the billing reimbursement conditions for each procedure, drug, and
medical device.
There are two major types of insurance schemes in Japan; Employees’ Health Insurance
and NHI. Employees’ health insurance covers those who are public servants or work in
companies, while NHI covers the self-employed and unemployed. Employees’ Health
Insurance is further divided into four major categories: Japan Health Insurance
Association (JHIA), Society Managed Health Insurance (SMHI), Mutual Aid
Association, and Seamen’s Insurance. Japan does not have a single insurance fund;
insurers are divided into approximately 3000 organizations.
Moreover, the premium rate largely differs from one insurance scheme to the next; this
fragmentation is a source of inefficiency in the system and 44 inequity in premiums.
Although there are several cross-subsidy systems among insurance schemes, mainly for
the financially weak NHI, financial sustainability and equity among insurance schemes
remain major challenges for the Japanese health financing system, especially when one
takes into account the rapidly ageing society.
1.15.1.12 Sources of revenue and financial flows
The Japanese health-care system is primarily funded through insurance premiums
subsidized by taxes. Both the Central Government and the municipalities levy
proportional income taxes and insurance premiums on their respective populations.
According to National Health Care Expenditure (NHCE), insurance premiums contribute
to 48.7% of financial contributions followed by public subsidies (38.8%) and patients’
copayments (11.7%) (Ministry of Health, Labour and Welfare, 2014a).
Thus, the researchers concluded that for the past decades, Japan has ranked high in a
range of population health metrics including the world’s longest life expectancy. Thanks
to its overall effectiveness of the health system and paralleled advances in technology,
Japan has for many years enjoyed increased life expectancy along with decreased
maternal and infant mortality and burden of communicable diseases. While this was
achieved through various socioeconomic factors, the health care system guided by the
principles of a universal health insurance system undoubtedly played a major role. Since
its founding in 1961, the universal health insurance system in Japan has provided
comprehensive coverage to all Japanese citizens.
Japan’s health system is characterized by universal insurance scheme through social
insurance premiums and tax subsidy, where participants are free to choose health care
facilities and good quality of care with comparably low price. However, as a greater
proportion of the population can expect to live a long life, in recent decades the incidence
of NCDs such as obesity and diabetes have increased significantly. This rise, along with
population ageing, continues to place strain on the national health system. Coupled with
over two decades of economic slowdown, Japan must now find policies that balance
universal coverage, support for the elderly, and financial sustainability.
The Ministry of Health, Labor and Welfare is the central leading institution in Japan’s
health system. The structure of the MHLW is complex, as well as the manner in which it
interacts with other ministries, insurance associations, the private sectors including health
care industries, care providers and patient and professional organizations such as the
Japan Medical Association and Japanese Nursing Association. Although one of the
unique attributes of Japanese health care system is that most of the services are provided
through private organizations, the government regulates and controls nearly all aspects of
the health system, 190 particularly a uniform fee schedule, at three levels national,
prefectural, and municipal. One of the characteristics of Japanese health care system is its
free access to health care facilities. Compared to other OECD countries, inpatient care in
Japan is characterized by longer average hospital stays with a greater number of inpatient
beds per capita with comparably low number of physicians. The number of physicians
and nurses per 1000 were 2.35 in doctors and 9.06 in nurses. Although its number of
nurses is higher than the 8.3 average in OECD, the number of physicians is below that of
OECD average of 3.02. This is likely to be caused by the ease of access to the health care
system at any point. This style of system has financial consequences that need to be
accounted for. Japan’s policy of tight control of health-care cost and a laissez-faire
approach to service delivery, with inadequate governance of provider organizations,
created a mismatch between need and supply of health-care resources and impeded
accountability for care quality.
Moreover, The goal of Japan Vision: Health Care 2035 is to build a sustainable health
care system that delivers better health outcomes through care that is responsive and
equitable to each member of the society and that contributes to prosperity in Japan and
the world. To attain this goal, the panel proposed three main pillars of reform: lean
healthcare (implement value-based healthcare), life design (empower society and support
personal choice) and global health leader (lead and contribute to global health). Bearing
in mind these transformations by 2035, reforms to the financing system and greater
efficiencies, with focus on outcomes, quality and efficiency, care and integrated
approaches across sectors, will be necessary to maintain a low-cost, equitable health
system in the future. (Sakamoto H, Rahman M, Nomura S, Okamoto E, Koike S,
Yasunaga H et al. Japan Health System Review. Vol. 8 No. 1. New Delhi: World Health
Organization, Regional Office for SouthEast Asia, 2018.)

1.15.2.1Conceptual Framework
Dependent Variable Independent Variable
Unwarranted Claims Private Employers who

are:
1. Non-Remitting
2 Under-Remitting
3 Delinquent
4. Non- Reporting
Intervening Variables
Members under these categories:
1. Indigents
2. Sponsored- Local Government
3. Senior Citizen
4. Lifetime member
5. Domestic Workers or Kasambahays
Figure 4.Conceptual Framework
Figure 4 shows the relationship of Dependent Variable, Independent Variable and Intervening
Variables to each other. With reference to the figure above, the Conceptual framework shows
that for benefit availment in both Accredited Private and Government Hospitals of Employed
members they are required to submit a form called Claims Form 1 or known today as Claims
Signature Form which will be certified by the employer. On the Part IV of the form, the
employer is certifying that his/her employee has the required 3/6 monthly premium contributions
plus at least 6 months contributions preceding the 3 months qualifying contributions within 12
month period prior to the first day of confinement (sufficient regularity) have been regularly
remitted to PhilHealth. The form was then revised on September 2018 and now called as Claims
Signature Form and the Employer Certification is now on the Part II of the form.
With reference to the eligibility requirement, consistent with the new guidelines on eligibility for
old members and in compliance with PhilHealth Circular No. 2019-0004, the circular defined the
parameters that will determine the sufficiency and regularity of premium payment. PhilHealth
Board Resolution no 209, s-206 declares that “… to establish sufficient regularity of payment,
members should have paid six (6) months contributions preceding the three (3) months
qualifying contributions within twelve (12) month period prior to the first day of availment…”
Further, the unwarranted Claims (Dependent Variable) are mostly billed to private employers
that are delinquent, under-remitting, non-remitting and/or non-reporting (Independent Variables)
because of certifying the Claims Signature Form of their employees knowing that they have
insufficient premium contributions to suffice the mandate of PhilHealth.
With reference to Section 18(d) of the Revised Implementing Rules and Regulations (RIRR) of
the National Health Insurance Act of 2013 on the Payment of Premium Contributions: “The
Failure of the employer to remit the required contribution and to submit the required remittance
list shall make the employer liable for reimbursement of payment of a properly filed claim in
case the concerned employee or dependent/s avails of Program benefits, without prejudice to the
imposition of other penalties as provided for in this rules.”
Relative to this, The Corporation issued PhilHealth Circular No. 0028- 2015 on the Quality
Procedures for the Recovery of Payments for Properly Filed Claims by Employed Members but
Without Qualifying Contributions (Unwarranted Claims). The coverage of the order shall apply
to claims duly paid for by PhilHealth for employee-members and/or their qualified dependents
but without qualifying contribution (unwarranted claims), whose employer is delinquent, under-
remitting, non-remitting and/or non-reporting. The order shall also apply to employers who
retain services of accounting firms which include, but not limited to payment and remittance of
PhilHeallth premiums in behalf of the employer and their employees and the submission of
corresponding reports.
Moreover, the information supplied by the member or his/her representative on Part I of the form
are consistent with the corporation’s available records As such, the corporation is obligated to
request for reimbursement of the amount of the benefit availed by the member or dependent/s.
It can also be observed that there are identified intervening variables that prevent the employers
from having Unwarranted Claims. The variables stated in the conceptual frameworkare
Indigents, Sponsored- Local Government, Senior Citizen, Lifetime member and Domestic
Workers or Kasambahays. Members under these categories are covered by the No Balance
Billing Policy.
1.15.2.2 No Balance Billing Policy
With reference toPhilHealth Circular No. 2017- 0006 and Section 43 of the Implementing
Rules and Regulation of Republic Act No 10606 (National Health Insurance Act of 2013)
re: No Balance billing Policy, relative thereto the policy covers members and dependents
of the categories, to wit:
 Indigent
 Sponsored
 Domestic Worker or Kasambahay
 Senior Citizen
 Lifetime members
The General Policies stated in the circular are:
A. Under the No Balance Billing Policy, no other fees or expenses shall be
charged or be paid for by qualified No Balance Billing (NBB) Patients above and
beyond the packaged rates.
B. Health Care Institutions shall be responsible and accountable for the care of
patients and in achieving the best outcome. They shall extend all medical and
financial support to qualified NBB members and dependents. They shall not deny
access to health services whenever necessary.
C. Health Care Institutions must give NBB Patients preferential access to their
social welfare funds or other sources for financing such as Philippine Charity
Sweepstakes Office (PCSO) and Medical Assistance Program (MAP), which may
be used to augment the benefit package provided in case of insufficiency to fully
cover all facility charges.
D. All Health Care Institutions shall ensure to deliver utmost quality of care and
provide complete medical and non-medical care, including but not limited to,
drugs, supplies (e.g., implants, plates, screws, pins, straps), diagnostics and other
medically necessary services like provision of adequate patients’ meals based on

prescribed therapeutic diet, nutritional status and dietary requirements, to achieve
the best possible outcome.
E. If the patients’ condition requires stay in the Intensive care unit, isolation room,
recovery room and other special accommodation, this shall be provided to the
patient and the NBB Policy shall apply.
Having stated this, The No Balance Billing (NBB) policy enables the vulnerable sectors
of the program such as the poor and the elderly to pay no more in excess of their
PhilHealth coverage when confined in government facilities. Further, they are intervening
variables since they do not need premium contributions in order to avail PhilHealth
Benefits in both Government and Private Hospitals which do not result to Unwarranted
Claims. Further, employers are not required to certify in the part IV of the form since
their membership category will already suffice for benefit availment.
Relative thereto, employers have the impression that since they are covered under the
policy they do not need to remit their employees’ premium contribution and not
deducting the same to their payrolls but with reference to the legal sanctions and penalties
of provisions stated in the IRR :
 “Section 178 on the Failure of Refusal to Register/Deduct Contributions- Any
employer or officer who fails or refuses to register/deduct contributions from
the employee’s compensation shall be penalized with a fine of not less than
Five Thousand Pesos (Php 5,000.00) multiplied by the total number of
employees of the firm.

 “Section 179 on the Failure or Refusal to Remit Contributions – Any
employer or officer authorized to collect contributions who, after collecting or
deducting the monthly contributions due from the employees, fails or refuses
to remit said contributions to the Corporation within thirty (30) days from the
date they become due shall be punished with a fine of not less than Five
Thousand Pesos (Php 5,000.00) but not more than Ten Thousand pesos (Php
10,000) multiplied by the total number of employees of the firm.”
Thus, employers and employee are mandated by law to deduct and be deducted on their
pay slip regardless of category as long as they are employed making them dual category
members.
CHAPTER 2
METHODOLOGY
This chapter will discuss the researcher’s method of gathering the necessary data. It will also
determine the type of research to be used that will be influential to the recommendations of the
research, also stating the location of the research conducted and the instrument used that is
needed for the interpretation of data.
2.1 Research Design
The type of research to be used in the study is both quantitative and qualitative. The quantitative
method will be used to quantify the total number and amount of Unwarranted Claims received
and also the number of employers affected to be able to provide a better perspective in drawing
out a statistical conclusion. The qualitative method will be descriptive based on the collected
data then an observation will be presented.
2.2 Research Locale
The research was conducted in Philippine Health Insurance Corporation Regional Office IX
located in BGIDC Corporate Center, Governor Lim Avenue, Zamboanga City. It will base on
Private Employers within Zamboanga City.
2.3 Research Instrument

The instrument to be used in the study was data extracted on Properly Filed Claims without
qualifying Contribution (Unwarranted Claims) from PhilHealth’s System through N-Claims
from Benefit Administration Section and through Interview Method within the premises of the
Office.
2.4 Respondents of the Study
The respondents will be from the Management, The Philhealth Accounts Management
Monitoring Officer, Employers with the most number of Unwarranted Claims and employees
who requests for certification of Claims Signature Form and the Employees requesting for
certification.
2.5 Data Gathering Procedure
The Philippine Health Insurance Corporations released Office Order No. 0028-2015 on the
Quality Procedures for the Recovery of Payments for Properly Filed Claims by Employed
Members but Without Qualifying Contributions (Unwarranted Claims). As such, these are the
following procedures to be followed when extracting data relative to Unwarranted Claims, to
wit:
1. The Benefit Administration Section will generate report/list of employers with
employees with properly filed claims but no qualifying premium contributions using the
N-Claims. The report will contain the details of the claim and the employer.
2. This generated reported will be forwarded to Collection Section.
3. The Collection Section will be responsible for the validation of premium contributions
of employers in the list thru PMAIS Treasury Database. This is also in coordination with
the Membership Section; it should be ensured that the actual employer at the time of
availment is properly identified.
4. If verified without qualifying contributions, the Collection Section will Draft billing
statement/ demand letter to be signed by the Regional Vice President with attached copy
of properly filed Claims Form 1 or Claims Signature Form and will be sent to the
employer.
Moreover, the Qualitative data will be gathered through Interview Method by endorsing a
request to conduct Interview within the premises of the office.
2.6 Statistical Treatment of Data
Upon the completion of data gathering, the researcher will sort and summarize the data. It will
clearly present the information for comprehensive analysis. Moreover, the researcher will
analyze these data through charts and give an interpretation based on the analysis of the result on
the conducted Interview.

CHAPTER 3
RESULTS
This chapter will present the analysis and interpretation of data that will be used to formulate the
recommendation. The results were gathered though data extraction on Properly Filed Claims
without qualifying Contribution (Unwarranted Claims) from PhilHealth’s System through N-
Claims from Benefit Administration Section. Furthermore, In giving an extensive analysis,
interview method was also used.
From 2012 to 2018, PhilHealth has received many Unwarranted Claims. As of September 2019,
the Unwarranted Claims in Zamboanga City has accumulated to a total of P 7,162,067.00 with
673 Claims from different private employers. Out of this amount, 71 claims amounting to
P742,940.00 have already been processed and billed to employers.
Hence, the researcher will be presenting statistics of the data of Unwarranted Claims of
Employers having the most number accumulated and the probable causes of their continuous
certification of Unwarranted Claims.

3.1 Presentation
No. of Unwarranted Claims

200
180
160
140
120 No. of Unwarranted Claims
100
80
60
40
20
0
2012 2013 2014 2015 2016 2017 2018
Figure 5. Number of Unwarranted Claims per Year (2012-2018)
Figure 5 shows the number of Unwarranted Claims through the years. As can be observed, the
most number of Unwarranted Claims accumulated was during 2017 with a total number of 189,
next in line are 2018 with 136 claims, 2016 with 162 claims, 2014 with 96 claims, 2015 with 88
claims and lastly 2012 and 2013 with only 2 claims each.
To be able to further understand the data presented. A pie chart will be shown to classify the
types of employers that contribute to the number of Unwarranted Claims.
No. of Unwarranted Claims

2% 1% 1% 1%
3% Security
3% Fishing
21% Manpower
4% Marketing
School
5% Canning
Shipping
Construction
6% Restaurant
Transportation
Hotel
7% Hospital
21% Manufacturing
Others
7%
18%
Figure 6.Number of Unwarranted Claims by Private Employers
Figure 6 shows the percentage of Private Employers relative to the number of Unwarranted
Claims in Zamboanga City. The data gathered has a total number of Unwarranted Claims within
Zamboanga City of 672. Out of the total number, Security Agencies consume most part of the
pie with 22% out of 100%. Next are the Fishing Companies with 21%, Manpower Agencies with
18%, Marketing Companies and School with 7% each, Canning Companies with 6%, Shipping
Companies with 5%, 4% goes to Construction Companies, Restaurants and Transportation
Companies with 3%, Hotel with 2% and lastly Hospitals, Manufacturing Companies and Other
companies such as Retail Businesses consume 1% of the Pie.
40
35
30
25
2014
2015
20
2016
2017
15 2018
10
0
Security Fishing Manpower Marketing School
Figure 7.Number of Unwarranted Claims by employer per yer
Figure 7 summarizes the data of the Top Employers with the most number of Unwarranted
Claims through the years. For 2014 and 2015 , the Fishing Companies garnered the most number
of Claims with a total of 18 and 13 claims, respectively. For 2016, Manpower Agencies were the
top with a total of 30 claims. For 2017, Security Agencies is on top with 36 claims and lastly for
2018, the Fishing Companies had the most with 23 claims.
3.2 Analysis and Interpretation of Data
To help explain further the data presented, an interview was made to be able to understand the
different perspectives of the cause of these Unwarranted Claims. The researcher’s respondents
include the person directly involved in the processing of billing the employers for Unwarranted
Claims, the PhilHealth Accounts Management Monitoring Officer, the PhilHealth Employers
Engagement Representatives of employers with the most number of Unwarranted Claims and
those employees who requests for certification of Claims Signature Form.
According to the Management, an employer certifying the Claims Signature Form should have
knowledge of the fact that his/her employee/s should have the required 3/6 monthly premium
contributions plus at least 6 months contributions preceding the 3 months qualifying
contributions within 12 month period prior to the first day of confinement (sufficient regularity)
have been regularly remitted to PhilHealth. Otherwise, they will be billed for reimbursement of
benefits availed by the employee.

Moreover, in preventing employers from under-remitting, non-remitting and not reporting their
employees of PhilHealth premium contributions, the corporation strictly adhere to Section 18(d)
of the Revised Implementing Rules and Regulations (RIRR) of the National Health Insurance
Act of 2013 on the Payment of Premium Contributions: “The Failure of the employer to remit
the required contribution and to submit the required remittance list shall make the employer
liable for reimbursement of payment of a properly filed claim in case the concerned employee or
dependent/s avails of Program benefits, without prejudice to the imposition of other penalties as
provided for in this rules.” Thus, billing employers for every employees they under-remitted, did
not remit and reported.
In response to the query on the duration of billing the employers for non-compliance to the
policies mentioned, they first visit the employer requesting for their books since they are
mandated by the law stated in Section 15.e of the Revised Implementing Rules and Regulations
(RlRR) of the National Health Insurance Act of 2013 on the Obligations of the Employer states
that "All government and private employers are required to allow the inspection of its premises
including its books and other pertinent records.” Also, Section 221 of the same RIRR on the
Visitorial powers of PhilHealth further states that “Any representative of the Corporation as duly
authorized by the President and CEO or by the concerned Regional Vice President shall have the
power to visit, enter and inspect facilities of health care providers and employers during office
hours, unless there is a reason to believe that inspection has to be done beyond office hours, and
where applicable, secure copies of their medical, financial, and other records and data pertinent
to the claims, accreditation, premium contribution and that of their patients or employees, who
are members of the Program.” Moreover, the PhilHealth Accouns Management Monitoring
Officer shall validate the employers’ books and shall be billed when there are discrepancies to
the remittances and reporting made by the employer.
Lastly, as far as their programs are concerned, the employers are much aware of these claims
since it is their main duty to market PhilHealth and spread awareness of its programs through
Information Education Campaign (IEC) throughout the Zamboanga Peninsula. Unfortunately,
even with the conduct of Information Education Campaign; employers still encounter these
claims since they fail to validate the employees’ PhilHealth contributions. It is the Corporation’s
mandate to always reach-out to employees and give the best service it can provide. Nevertheless,
the management still experience repercussions. Since these Unwarranted Claims affect the
Corporation’s budget which will result to a loss of funds.
Moreover, According to the PhilHealth Accounts Management Monitoring Officer, these
Unwarranted Claims are a result from Under-Remitting, Non-Remitting, Non-Reporting
employers. It is already understood that once you are under these categories you are
automatically certifying Unwarranted Claims. I have also asked the respondent regarding the
figures presented and they have mentioned that recruitment agencies are the ones who are
frequently certifying these Unwarranted Claims since most of the agents they have hired are
covered either under the special laws or are not reporting to duty. With the lack of knowledge
regarding this matter, the employers just certify. Lastly, I have also asked regarding the
accessibility of the Health Care Institutions regarding the matter on the endorsement of the
Claims Signature Form and they mentioned that the HCIs have limited access to contribution
history; they are instructed to let the employed-member fill-out the form since the responsibility
of validation is held by the employer as stated in the part II of the form.

According to one of the employers, whenever the PhilHealth section of the Health Care
Institution instructs their employee to let their employer certify the document; they trust that the
system has already validated the employees’ eligibility requirement thus their non-validation of
employees’ contribution. Other employers validate their employees by contacting their
PhilHealth Accounts Management Monitoring Officer and request for clearance of certification
to the document before submitting the latter to the Health Care Institution.
Moreover, they made mention of the impact of the claims to their business, they have discussed
with the employee who availed but should not have availed the benefits and have come to an
agreement of deducting the amount of claims availed directly to his/her payroll to compensate
the reimbursement Claim of the corporation yet for those who are already not with them, their
best option is to settle it internally which will incur loss to the company.
Unfortunately, most employers are not aware of the Legal Sanctions and they are only informed
through the billing statement they receive. Hence, their inability to inform their employees of its
impact.
Furthermore, most Employers hire services of Accounting or Bookkeeping Offices. They are not
updated of their remittances and reporting to the Electronic Premium Remittance System. Hence,
they are paying but they fail to monitor their remittances.
Lastly, according to the employees’ perspective, they only know that they are being deducted of
PhilHealth Premium Contributions but they fail to monitor their remittances through their payroll
officer. Whenever they avail of PhilHealth benefits, they only follow the mandatory
requirements since they are in dire need of the benefits thus the endorsement of the Claims
Signature Form to the Head of Agency for certication. In their knowledge, it is the responsibility
of the employer to validate the documents they are certifying. Whenever they receive the signed
document, they are relieved of the fact that they are eligible for availment. Most employees are
not fully aware of the repercussions in certifying the Claims Signature Form.
CHAPTER 4
DISCUSSION
4.1 Summary
The data presented shows that the private employers with the most number of Unwarranted
Claims are Security Agencies, Fishing Companies and Manpower Agencies.
With reference to the interview conducted with the PhilHealth Accounts Management
Monitoring Officer, most of the companies that commit to the certification of Unwarranted
Claims are recruitment agencies since most of the agents they have recruited are covered under
the special laws and others are not reporting to duty. With the lack of knowledge regarding this
matter, the employers just certify. He also added that employers under the categories of Non-
Remitting and Non-Remitting are automatically non-compliant thus any certification of
employees’ Claims Signature Form will result to Unwarranted Claims.Furthermore, the Health
Care Institutions have limited access to the members’ contribution history which is the reason for
their endorsement to the employed members of Claims Signature Form. The responsibility of
validation is held by the employer.
Moreover, the management mentioned that the amount of accumulated Unwarranted Claims
have made the corporation to report a loss since the companies who have certified these claims
are not reporting and remitting. Unfortunately, the employers and its employees fail to monitor
their remittances may it be to the accounting office they have requested for services or their
payroll officers, respectively.
4.2 Recommendations
Considering the problems stated,it is vital for the Private Employers and their employees to
monitor their remittances and reporting to prevent certification of Unwarranted Claims. The
impact of this certification are dealt with by PhilHealth through billing of reimbursement of
benefits availed by their employees per PhilHealth Circular No. 0028- 2015 re: Quality
Procedures for the Recovery of Payments for Properly Filed Claims by Employed Members but
Without Qualifying Contributions (Unwarranted Claims). In doing so, will require the employer
to plan a payment scheme. Since upon certification of the Unwarranted Claims, the corporation
has the authority to demand for the recovery of the loss incurred to replenish the budget it has
allocated for Health Care Delivery.
Thus, the researcher recommends for the improvement of the different systems involved in the
process. Firstly, the Electronic Premium Remittance System should be enhanced having the
function to notify its members of their payment lapses which will highly likely reduce the non-
remitting and non-reporting employers. Also, enhancements should also be done to the eClaims
or iCares Portal having the access to view the members’ contribution history for them to advise
members of their lapses before the form will be endorsed and certified. Improving both these
systems will likely result to a reduction of the certification of Unwarranted Claims.
Furthermore, as stated by the management of PhilHealth, they are continuously conducting
Information Education Campaigns and employer visits. These activities will inform the
employers and employees of the consequences and the impact of these claims which is the first
step in the prevention of the occurrence of the accumulation of Unwarranted Claims. Moreover,
any questions or hesitations in the certification of the document can always be directed to the
PhilHealth Regional Office, Local Health Insurance Offices or their designated PhilHealth
Accounts Management Monitoring Officer for validation and confirmation. Lastly, the
employers and its employees should always monitor their premium contributions and any
observations can always be addressed to the party concerned to prevent repercussions.

REFERENCES
National Health Insurance Act of 2013
PhilHealth Circular No. 2015-016
Koike S, Nomura S., Okamoto E, Rahman M , Sakamoto H, Yasunaga H et al. (2018). New
Delhi: World Health Organization, Regional Office for South-east Asia. Japan Health
System Review, (8)1.
Revised Implementing Rules and Regulations (RIRR) of the National Health Insurance Act of
2013
PhilHealth Circular No. 2017- 0006

APPENDIX
ANNEX
January 30, 2020
EDGARDO F. FAUSTINO
Acting Regional Vice President
PhilHealth Regional Office IX
BGIDC Bldg., Gov. Lim Avenue
Zamboanga City
Dear Mr. Faustino,
Greetings!
I am currently enrolled in the College of Public Administration (CPADS) – Western Mindanao

State University taking PA 244- Seminar in Governmental Studies and one of our requirements
is to conduct a research in the Public Administration discipline. Hence, I am in the process of
doing a research on “Assessing Private Employers’ Certification of Employees’
Unwarranted Claims in Zamboanga City”
In this connection, I am asking for your permission to use materials of the office as my
references and also conduct an interview within the vicinity of the office. These are needed to
strengthen my study for the drafting of the recommendation since I am doing both Qualitative
and Quantitative Research Methods.
Further, the data gathered will be kept strictly confidential and for academic purposes only. The
respondents’ participation in the study will be completely voluntary and the responses will be
anonymous.
Attached for your review is the Interview guide and Interview questions.
Your approval to the conduct of this study is highly appreciated.
Sincerely,
Aldrich C. Tan
Researcher
Noted by:
Bernard Q. Suriaga
Research Professor
INTERVIEW GUIDE
BACKGROUND
With reference to the Revised Implementing Rules and Regulations (RIRR) of the
National Health Insurance Act of 2013 regarding the payment of Premium Contributions, "The
failure of the employer to remit the required contribution and to submit the required remittance
list shall make the employer liable for reimbursement of payment of a properly filed claim in the
concerned employee or dependent/s avail of program benefits, without prejudice to the
imposition of other penalties as provided for in this rules."
The Corporation then issued PhilHealth Circular No. 0028- 2015 on the Quality Procedures for
the Recovery of Payments for Properly Filed Claims by Employed Members but Without
Qualifying Contributions (Unwarranted Claims).The coverage of the order shall apply to claims
duly paid for by PhilHealth for employee-members and/or their qualified dependents but without
qualifying contribution (unwarranted claims), whose employer is delinquent, under-remitting,
non-remitting and/or non-reporting. The order shall also apply to employers who retain services
of accounting firms which include, but not limited to payment and remittance of PhilHeallth
premiums in behalf of the employer and their employees and the submission of corresponding
reports.
Statement of the Problem Questions

1. What is the impact of these Unwarranted For PhilHealth:
Claims to PhilHealth, Private Employers and 1. What will happen if the employer certified
the Claims Signature Form or Claims Form 1
its employees? and the Member or Dependent availed of
PhilHealth Benefits?
2. How does an employer become

Delinquent, Under-remitting, non-remitting
and/or non-reporting?
3. How long until the corporation bill these

employers for non-compliance to the
aforementioned policies?
4. Are the employers and its employees

aware of this type of claims and its Legal
sanctions? How?
5. In billing these Unwarranted Claims, what

type of companies have you observed with
the most number you have billed and
processed?
For Employers:
1. Are you aware of this type of claims and

its legal sanctions?
2 How do you settle the billings forwarded

by PhilHealth?
2. What is your Payment Scheme?
For Employees:
1. Are you aware of this type of claims and

its legal sanctions?
2. What can be done to avoid Unwarranted For PhilHealth:
Claims by the corporation, employers, and 1. How do you inform the employers of the
concept of Unwarranted Claims?
employees? 2. Even with the conduct of Information

Education Campaign, Why do employers still
certify the CSF knowing the impact of this
claims?
For Private Employers:
1. Before certifying the CF1/CSF, How do

you validate the employees’ PhilHealth
Contributions?
2. Are you aware of the Legal Sanctions and

penalties?
3. Who processes the Claims Signature

Form/Claims Form 1 of your employees who
will be availing of PhilHealth benefits?
4. Although you have knowledge of

Unwarranted Claims, Why did you certify in
the Claims Signature Form or Claims Form
1?
For Employees:
1. Once you will be instructed by the

PhilHealth Office in a Health Care Insitution
to fill up the Claims Signature Form, what do
you do?
2. Are you monitoring your remittances?

How?
3. How does this affect the corporation’s For PhilHealth:
funds? 1. How does this affect the Corporation’s

budget for payment of claims?
2. Will the payment of Unwarranted Claims

be reverted back to the corporation’s budget?

Final Research 3

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Running head: ASSESSINGPHILHEALTH’S UNWARRANTED CLAIMS i

Western Mindanao State University

Assessing PhilHealth’s Unwarranted Claims to Private

concerned employee or dependent/s avail of program benefits, without prejudice to the

imposition of other penalties as provided for in this rules."

qualifying contribution (unwarranted claims), whose employer is delinquent, under-remitting,

blessings throughout the completion of my research.

I would like to express my deep and sincere gratitude to my PA 299 A – Research

I would also like to thank my colleagues from Philippine Health Insurance

another shared their support.

1.15.1.6 Growth and Equity 34

1.1 Background of the Study

which went for almost a quarter of a century.

Health Insurance Corporation (PhilHealth), mandated to provide social health insurance

coverage to all Filipinos in 15 years' time.

June 19, 2013.

minimum package and other supplementary packages of health insurance benefits by a

health care facilities. (Article III, Section 5 of RA 7875 as amended)

1.3 Powers and Functions

Philippine Health Insurance Corporation is a tax-exempt Government Corporation attached to

7875 as amended by RA 10606):

a) To administer the National Health Insurance Program;

satisfaction, and overall accomplishment of Program objectives;

d) To formulate and implement guidelines on contributions and benefits; portability of benefits,

methods, and referral systems;

e) To establish branch offices as mandated in Article V of this Act;

f) To receive and manage grants, donations, and other forms of assistance;

g) To sue and be sued in court;

attainment of the purposes of this Act;

accordance with the provisions of this Act;

of health services in behalf of its members;

provider organization, including but not limited to health maintenance organizations,

personal health services prescribed by the Corporation;

for the Program in accordance with this Act;

are members of the Program;

necessary and upon the recommendation of the president of the Corporation;

disbursements, reserves, average costing to beneficiaries, any request for additional

synopsis of such report in two (2) newspapers of general circulation;

facilitate efficient and effective services;

r) To invest in the acceleration of the Corporation’s information technology systems;

check the status of paid health premiums;

valid terms and conditions it may prescribe;

establishment of a comprehensive health database;

carry out necessary actions to enforce compliance;

doing business with a private individual or group;

z) To accredit independent pharmacies and retail drug outlets; and

contribution payments are equally shared by the employee and employer.

1. Government Employee- an employee of the government, whether regular, casual or

force, political subdivisions, agencies or instrumentalities, including government-owned

and-controlled corporations, financial institutions with original charter; Constitutional

Commissions, and is occupying either an elective or appointive position, regardless of

2. Private Employee - an employee who renders services in any of the following:

i. Corporations, partnerships, or single proprietorships, NGOs, cooperatives, non-profit

organizations, social, civic, or professional or charitable institutions, organized and based

in the Philippines including those foreign owned;

cover their Filipino employees in PhilHealth.

job order contractors, project-based contractors and the like

4. Owners of Micro Enterprises

5. Owners of Small, Medium and Large Enterprises

6. Household Help- as defined in the Republic Act of 10361 or “Kasambahay Law”

1. Migrant Workers – documented or undocumented Filipinos who are engaged in a

remunerated activity in another country of which they are not citizens.

3. Self-Earning Individuals – individuals who render services or sell goods as a means of

livelihood outside of an employer-employee relationship or as a career. These include