State auditors urged the Department of Health (DOH) to recover over P1 billion in denied and returned reimbursement claims of hospitals from the Philippine Health Insurance Corporation (PhilHealth).
This is as the Commission on Audit (COA) 2023 audit revealed government hospitals had P595.56 million in denied reim and P733.46 million returned to them due to non-compliance with Republic Act No. 7875, which established PhilHealth.
“The amount of P595,563,644.12 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.
State auditors referenced Section 38, Article VIII of Republic Act No. 7875, stating PhilHealth may deny or reduce claim payments for false or incorrect information or non-compliance with the law’s rules.
Auditors also highlighted Section 47 of the revised implementing rules and regulations (RIRR) of the law, stating that denied claims cannot be recovered from members. They noted that denied and returned claims led to hospitals’ income loss.
Common causes for the denied and returned claims include the absence or loss of records to support long-outstanding claims, improperly accomplished statement of account or claim signature forms, and incomplete or non-compliant documentary requirements.
Other factors include inconsistencies between encoded forms and data in attachments, cases that were not compensable, or those that exhausted compensable days or the allowed number of claims for an illness or procedure.
Additional reasons for denials include filing claims beyond the statutory period, violations of single-period confinement, lapses in the PhilHealth system, and constant changes in guidelines and requirements. Non-compliance with the minimum standard of care per patient also contributed to the issue.
The Southern Philippines Medical Center in Davao City had the highest denied and returned claims, totaling P406.64 million and P353.56 million, respectively.
Mayor Hilarion A. Ramiro Sr. Medical Center in Ozamiz City reported the second-highest denied claims at P93.24 million, with no returned claims.
Jose B. Lingad Memorial General Hospital in San Fernando, Pampanga had returned claims of P295 million and denied claims totaling P19.84 million.
In response, the DOH stated that the Accounting and Billing Unit is conducting “continuous reconciliation” with PhilHealth through a circular. The agency will also provide “refresher training” to PhilHealth claims processors to ensure the accuracy of member and patient information. (TCSP)
