REFUND claims filed by the National Kidney and Transplant Institute (NKTI) that were returned by the Philippine Health Insurance Corp (PhilHealth) for improper or insufficient documentation soared 382.8 percent between 2021 and 2022, government auditors revealed.
The NKTI audit report released on June 7 showed NKTI’s return-to-hospital (RTH) claims was at P50.32 million in 2021 but ballooned to P242.93 million last year.
Likewise showing an uptick were claims that were denied with finality, from P4.15 million in 2021 to P4.94 million in 2022.
“Claims for reimbursement… were returned to hospital and denied due to non-compliance with the documentary requirements and conditions provided under the revised Implementing Rules and Regulations of Republic Act No. 7875 or the National Health Insurance Act of 2013,” the Commission on Audit said.
Among the usual grounds cited were discrepancies/inconsistencies or incomplete data provided about the patient or the treatment; confinement for less than 24 hours; attending physician was not accredited by PhilHealth; cases that are not compensable under the implementing rules and regulations of RA 7875; and improperly accomplished claim forms.
NKTI management assured auditors that its personnel gave their best efforts but said the reasons of RTH and denied claims are beyond their control as they rest solely on the judgment of PhilHealth evaluators.
It also complained about the “constant change of guidelines and requirements implemented by PhilHealth,” which rendered claims previously acceptable to be deemed invalid based on revised conditions.
In its review of the hospital’s Billing and PhilHealth Section, the audit team noted that the NKTI staff refiled 59,630 out of 60,830 RTH cases as well as 8,888 out of 8,958 denied claims.
There were also 1,200 pending claims for refiling as of the year-end for appeal with PhilHealth.
COA expressed concern that the accumulation of uncollected accounts from PhilHealth could end up becoming income losses to NKTI that it could otherwise use to augment the cost of operations and to fund improvement of facilities.
