January 1, 2025 | 12:00am
MANILA, Philippines — The Commission on Audit (COA) has told the Department of Health (DOH) to explore all possible means to collect from the Philippine Health Insurance Corp. (PhilHealth) the denied and returned reimbursement claims of government hospitals which stood at P1.33 billion as of end of 2023.
Based on the COA’s 2023 annual audit report on the DOH released last Dec. 2, government hospitals’ claims for reimbursement totaling P595.56 million were denied by PhilHealth due to noncompliance with the requirements prescribed under the revised implementing rules and regulations (RIRR) of Republic Act 7875 or the National Health Insurance Act (NHIA) and other related PhilHealth issuances.
The COA said there were also claims amounting to P733.46 million which were tagged as “RTH” or returned to hospitals.
The claims with incomplete supporting documents or erroneous entries are being returned by PhilHealth to the concerned hospitals to give them the chance to address the deficiencies.
The COA pointed out that under Section 47(f) of the RIRR of the NHIA, denied reimbursement claims shall not be recovered from the patients or PhilHealth members. Thus, the accumulation of denied reimbursement claims translates to income loss of government hospitals’ operating units, adding that the huge amount of returned claims may also result in income loss if not addressed immediately.
“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,” the 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 state auditing body added that among the common causes for the denial or return of claims were absence or loss of records to support long-outstanding claims; improperly accomplished Statement of Account and Claim Signature Form; noncompliance with documentary requirements; inconsistencies with the encoded data as against the data in the attached documents; late filing; inclusion of non-compensable cases and cases that exceeded the allowable number of claims; “lapses in the PhilHealth system and constant change of guidelines and requirements implemented by PhilHealth” and non-compliance with PhilHealth’s “minimum standard of care per patient.”
“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,” the COA explained.
The audit breakdown showed that Southern Philippines Medical Center in Davao City had the biggest amount of denied and returned PhilHealth claims amounting to P406.64 million and P353.56 million, respectively.
While not having any returned claims, Mayor Hilarion A. Ramiro Sr. Medical Center in Ozamiz City, Misamis Occidental had the second highest amount of denied claims at P93.24 million, while Jose B. Lingad Memorial General Hospital in San Fernando, Pampanga had P19.84 million and P295 million in denied and returned claims, respectively.
Other government hospitals mentioned in the audit report were Davao Regional Medical Center in Tagum, Davao Del Norte with P29.76 million in denied claims; Northern Mindanao Medical Center in Cagayan de Oro City, Misamis Oriental with P22.41 million in denied claims and Dr. Paulino J. Garcia Memorial Research and Medical Center in Cabanatuan City, Nueva Ecija with P16.51 million and P39.27 million in denied and returned claims, respectively.
Likewise identified in the audit report were the San Lazaro Hospital in Manila with P3.05 million and P22.81 million in denied and returned claims, respectively; National Children’s Hospital in Quezon City with P35,000 and P15.2 million in denied and returned claims, respectively; Talavera General Hospital in Talavera, Nueva Ecija with P1.37 million and P1.91 million in denied and returned claims, respectively; Soccsksargen General Hospital in Surallah, South Cotabato with P1.04 million and P1.18 million in denied and returned claims, respectively; Southern Tagalog Regional Hospital in Bacoor, Cavite with P1.66 million in denied claims and Conner District Hospital in Conner, Apayao with P4.52 million in returned claims.
The COA, nonetheless, said the secretary of health, as well as the heads of the concerned government hospitals, have agreed to the audit recommendation to “make representation to the PhilHealth to determine the status of the receivables therefrom and inquire on the course of actions that can be done to facilitate collection.”
In a reply incorporated in the audit report, the DOH said there is an ongoing coordination with PhilHealth “to reconcile receivables and refine procedures for the denied claims.”
The DOH said it will also provide refresher training to the hospitals on the proper filing of PhilHealth claims and thorough review of the completeness and accuracy of members/patients’ information.
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