The Philippine Heart Center’s (PHC) claims filed in 2020 totaling P71.17 million have been denied by the Philippine Health Insurance Corporation (PhilHealth) due to government hospital’s purported failure to comply with the provisions of the Revised Implementing Rules and Regulations (IRR) of RA 7875 or the National Health Insurance Act, and relevant PhilHealth circulars.
This was bared by the state auditors in the 2020 audit of the PHC released on Wednesday, April 28.
The Commission on Audit (COA) noted that the denied and return to hospital (RTH) claims "resulted in accumulation of uncollectibles from PhilHealth and loss of income on the part of the PHC."
Based on the audit report, the PHC submitted 3,907 claims to the PhilHealth from Jan. 1, 2020 to Sept. 30, 2020.
"Based on the information provided by PhilHealth Regional Office, National Capital Region (NCR)-Central, there were about 3,907 claims totaling P71.170 million for reimbursement of benefits submitted by PHC to PhilHealth that have been denied and returned to the Center for the period January 1, 2020 to September 30, 2020,” the government auditors said.
As of Sept. 30, 2020, there were 2,432 denied claims worth over P38.919 million and 1,475 RTH claims amounting to P32.25 million, according to the summary provided in the audit report.
Based on PhilHealth Circular No. 2019-001 dated Jan. 10, 2019, denied claims are those that have been determined to be invalid and unworthy of payment/reimbursement due to an absolute deficiency that cannot be remedied through RTH or due to a finding of an unmet requirement.
The circular defines RTH claims as a “deficient claim after due adjudication and validation, redirected back to health care institution (HCI) with instructions to comply with certain requirements, but from which the action of returning the complied claim to PhilHealth may result in the reversal of the deficiency into a good claim or non-compliance that may result into the denial of the claim.”
The audit team said verification of the records of the Billing and Claims Division disclosed the following reasons or deficiencies for the disallowed/denied and RTH claims: late filing beyond the allowed period of 60 days; inconsistent/incomplete data/ non-submission of other documents; confinement for less than 24 hours; case rate claim attended by non-accredited physician; case not in the compensable list; violation of single period confinement, claims forms not properly accomplished, and failure to submit readable claims online.
"The denied and RTH claims amounting to P71.170 million increased the uncollectible receivables from PhilHealth, which collection thereof could have been used to augment the requirement of PHC for maintenance and other operating expenditures, including repair of existing hospital facilities. Likewise, this is another loss of income on the part of PHC,” the COA said.
The PHC management told COA that the RTH or denied claims are being returned by PhilHealth through Billing and Claims Division. "Once received, claims were evaluated, complied with the deficiencies and prepared appeals to PhilHealth within the prescribed timeline," the PHC said.
It assured COA that the Billing and Claims Division "will exert extra effort to review and evaluate all claims forms to avoid possible deficiencies or to minimize disallowances (if not all).”
"Appeals to PhilHealth shall likewise be continuously done,” it added.