The façade of the PhilHealth Head Office in Pasig City on September 5, 2020. George Calvelo, ABS-CBN News/File

MANILA — The Commission on Audit (COA) has directed the Department of Health (DOH) to facilitate the collection of denied and returned reimbursement claims of hospitals worth over P1 billion from the Philippine Health Insurance Corporation (PhilHealth).

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COA's 2023 annual audit report showed government hospitals had claims worth P595,563,644.12 which were denied for reimbursement by PhilHealth. Another P733,460,070.67 were classified as RTH or returned to hospital due to non-compliance with provisions of Republic Act No. 7875 or the law creating the state-run health insurer.

The audit team also observed non-compliance with other related PhilHealth issuances.

State auditors cited Section 38, Article VIII of Republic Act No. 7875, which states that PhilHealth may deny or reduce payment of claims if they have false or correct information and when the claimant fails to comply with the rules of the law.

It also pointed out Section 47 of the revised implementing rules and regulations (RIRR) and the law, which said denied claims shall not be recovered from the member.

State auditors said the denied and returned claims resulted in the hospitals' loss of income.

“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.

Common causes for the denied and returned claims include:

• Absence/loss of records to support long outstanding claims

• Improperly accomplished statement of account and/or claim signature form

• Incomplete/non-compliance with documentary requirements

• Inconsistencies between encoded forms and data in attachments

• Case was not compensable or exhausted compensable days or allowed number of claims for the illness/procedure was reached

• Filing of claims beyond the statutory period

• Violation of single-period confinement

• Lapses in the PhilHealth system and constant change of guidelines and requirements

• Non-compliance to 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," COA said.

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Regions with denied and returned claims to hospitals include 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 at P406.64 million and P353.56 million each.

Mayor Hilarion A. Ramiro Sr. Medical Center in Ozamiz City recorded the second highest amount of denied 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 and the Health Secretary agreed to direct the heads of concerned hospitals to "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 agreed to was to establish hospital policies that would enjoin concerned divisions to reconcile the balances, settlement and monitoring of denied and returned PhilHealth claims.

In response, the DOH said there is "continuous reconciliation" being done by the Accounting and Billing Unit with PhilHealth through a circular. The agency will also 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.

"The management remains committed to compliant filing, document submission, and timely claim processing to avoid RTH and denied claims, with on-going efforts to facilitate reconsideration of eligible claims by PhilHealth," it further read.

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