DENIED and returned reimbursement claims of the Philippine Heart Center (PHC) from the Philippine Health Insurance Corporation (PhilHealth) have ballooned to P167.84 million in 2021 compared to P71.17 million in 2020, according to a report released by the Commission on Audit released yesterday.
Government auditors said the 2021 figure was based on PHC’s full year billing while the 2020 total only covered claims from January to September 2020.
A breakdown presented by the audit team showed denied claims amounted to P48.91 million while return to hospital (RTH) claims reached P119.03. The figures represented 723 denied claims and 4,142 RTH claims.
RTH claims are billings that are found to be deficient in documentation or other requirements and are sent back to the health care institution for compliance and further validation.
The PHC Claims and Billings Division said among the grounds for the denial of a claim is failure to meet the 60-day submission period; inconsistent or incomplete data; patient’s confinement was less than 24 hours; patient was attended by a non-accredited physician; case is not covered by PhilHealth benefits; and improperly filled-out claim forms.
Auditors warned the PHC management that it should address the problem since unpaid PhilHealth reimbursement claims would hurt its operational funding.
“It is emphasized that the increased probability of non-collection of claims might result in possible income loss, depriving PHC of the fund which can be used to augment their operational budget,” the COA pointed out.
The state hospital admitted that there were issues about its documentation caused by the modifications in the previous PhilHealth guidelines.
“According to PHC personnel in-charged in the processing of PhilHealth claims, there were some updates in the PhilHealth guidelines that were not communicated to them hence, deficiencies in the claims filed occurred,” the audit team said.
Earlier, two other state-owned hospitals, the Lung Center of the Philippines (LCP) and the Philippine Children’s Medical Center, also cited PhilHealth’s changing rules and guidelines as the reason for their trouble in complying with documentation.
Separate audit reports released last April 7 showed the LCP posted P5.852 million in denied claims and P245.681 million in return to hospital (RTH) claims while PCMC had P943,477 denied claims and P24.754 million RTH claims.
