The Commission on Audit (COA) has directed the Department of Health (DOH) to hasten the collection of denied reimbursement claims of state-run hospitals amounting to over P1 billion from the Philippine Health Insurance Corp. (PhilHealth).
COA’s 2023 annual audit report showed government hospitals had claims worth P595,563,644 which were rejected by PhilHealth.
Another P733,460,070 classified as RTH (returned to hospital) due to non-compliance with provisions of the PhilHealth Law (Republic Act No. 7875).
COA also cited non-compliance with other related PhilHealth issuances.
State auditors cited however, Section 38, Article VIII of RA 7875 stipulating that PhilHealth may deny or reduce payment of claims that have false or incorrect information, or if the claimant failed to comply with pertinent guidelines.
It also pointed out Section 47 of the revised implementing rules and regulations (RIRR) and the law, which stated that denied claims should not be recovered from the concerned member.
COA pointed out that the denied and returned claims resulted in the hospitals’ loss of income.
“The amount of P595,563,644 is a significant loss of income as it could have been used to augment its fund requirements for operation and improving the existing hospital facilities,” COA said.
“The returned claims amounting to P733,460,070.67, which are recognized as receivables by the concerned operating units, exposed them as vulnerable to possible loss of income,” it added.
“The lapses relative to the preparation and filing of the hospital’s claims from PhilHealth would make an impression that certain policies and procedures were not duly observed, particularly in ensuring that claims are completely supported with required documents appropriately filled up, resulting in the return of filed claims,” COA noted.
Regions with denied and returned claims to hospitals included the National Capital Region, Cordillera Administrative Region, Central Luzon, CALABARZON, Northern Mindanao, Davao Region and SOCCSKSARGEN.
The Southern Philippines Medical Center (SPMC) in Davao City topped the list for denied and returned claims amounting to P406.64 million and P353.56 million, respectively.
The Mayor Hilarion Ramiro Sr. Medical Center in Ozamiz City came in second with claims at P93.24 million, but did not have any returned claims.
Jose B. Lingad Memorial General Hospital in San Fernando, Pampanga had returned claims amounting to P295 million and denied claims worth P19.84 million.
The COA recommended that the heads of concerned hospitals should “make representations to the PhilHealth to determine the status of the receivable therefrom and inquire on the courses of actions that can be done to facilitate collection.” Another audit recommendation was to establish hospital policies that would enjoin concerned divisions to reconcile the balances, settlement and monitoring of denied and returned PhilHealth claims.
The DOH asserted there was “continuous reconciliation” being done by the Accounting and Billing Unit with PhilHealth through a circular. The agency also offered to provide a “refresher training on filing of claims to PhilHealth claims processors” to review the accuracy of the member/patient’s information.
“Management claimed that denial is not a loss of revenue and that there is a huge disparity between the receivables computation of DOH offices and PhilHealth. Round table discussions were held for the reconciliation of receivables,” the report stated.
