THE Philippine Heart Center (PHC) reported P110.062 million in denied and return-to-hospital (RTH) claims for reimbursement with the Philippine Health Insurance Corp. (PhilHealth) in 2022.
While this was lower than the P167.84 million posted in 2021, the Commission on Audit (COA) warned that the amount still represents a “material loss of income to the PHC” that it could have used to fund operations and improve existing hospital facilities.
Figures from the 2022 audit report showed denied claims numbered 263 equivalent to P27.58 million. On the other hand, there were 696 RTH claims representing P82.48 million in reimbursement requests.
Denied claims were already determined to be invalid due to an “absolute deficiency” that cannot be remedied by RTH mode.
RTH claims on the other hand are appealable although the hospital is required to submit additional documents or to make corrective steps within a set deadline.
In 2021, PHC’s denied claims amounted to P48.91 million while RTH claims reached P119.03.
The state hospital’s Billing and Claims Division assured the COA that it is regularly monitoring the denied and RTH claims to be able to file motions for reconsideration within the allowed period.
It added that there are also personnel assigned to participate in reach-out activities with PhilHealth to update the PHC system and address gaps in implementing PhilHealth guidelines.
Despite this, the PHC said it is encountering difficulty complying because of frequent modifications in the processes and requirements.
“The BCD averred that despite their efforts, the reasons for denied and RTH claims are beyond their control and rest solely to the discretion of PhilHealth adjudicators/evaluators, lapses in the PhilHealth system, and the constant change of guidelines and requirements implemented by PhilHealth, thus affecting the validity and effectivity of submitted claims,” the auditors said.
