P111M claims of gov’t hospitals denied for non-compliance: COA


    THE Philippine Health Insurance Corporation (PhilHealth) denied government hospitals of some P111.15 million in reimbursement claims last year, according to a 2019 audit report on the Department of Health.

    The Commission on Audit said PhilHealth’s denial was due to the failure of public hospitals to comply with regulations under RA 7875 or the National Health Insurance Act of 1995 governing reimbursement to healthcare providers of medical cost incurred by PhilHealth member-patients.

    “This condition has resulted in the hospitals’ loss of income which could have been used to augment their operating requirements,” government auditors said.

    Under the revised implementing rules and regulations (RIRR) of RA 7875, PhilHealth is authorized to penalize healthcare providers for non-observance of the rules by denying their claims.

    Among the grounds cited were over-utilization of services; unnecessary diagnostic and therapeutic procedures; irrational medication and prescriptions; fraudulent, false or incorrect information; and use of fake, adulterated or misbranded pharmaceuticals, or unregistered drugs.

    When a claim is denied, the hospital ends up absorbing the cost of treatment and medication.

    The DOH management agreed with the audit team’s recommendation to analyze the grounds for disapproval of PhilHealth’s claims, and to formulate guidelines for easier compliance by healthcare providers.

    It also reiterated its adherence to the RIRR of RA 7875 and to ensure that all claim forms are properly prepared prior to processing.

    Government hospitals in Metro Manila incurred the lion’s share of denied reimbursements accounting to a whopping 69 percent or P76.7 million followed by Region 2 or Cagayan Valley (12 percent or P13.34 million). Regions 1 (Ilocos Region) and 10 (Northern Mindanao) each accounted for six percent of the total. equivalent to P6.67 million.

    On a per hospital basis, the biggest amount of denied claims was posted by the Dr. Jose N. Rodriguez Memorial Medical Center in Tala, Caloocan City, with P63.144 million or 56.8 percent.

    Coming in at second with P7.54 million in denied claims (6. 78 percent) is Cagayan Valley Medical Center with Mayor Hilarion A. Ramiro Sr. Medical Center at third with P6.4 million.

    At fourth place is San Lorenzo Ruiz Women’s Hospital in Malabon City (P5.77 million).