TWO government-owned hospitals have complained about the erratic policies of the Philippine Health Insurance Corporation (PhilHealth) that have adversely affected collectability of reimbursement claims of bills incurred by its members.
Separate reports released by the Commission on Audit last April 7 showed the Lung Center of the Philippines (LCP) and the Philippine Children’s Medical Center (PCMC) have raised issues of inconsistency against PhilHealth.
As of yearend 2021, the LCP posted P5.852 million in denied claims and P245.681 million in return to hospital (RTH) claims.
On the other hand, PCMC’s denied claims totaled P943,477 while RTH claims amounted to P24.754 million.
In both cases, the PhilHealth cited the grounds of non-compliance with proper documentation and conditions set under PhilHealth circulars and the Revised Implementing Rules and Regulations (RIRR) of RA 7875 or the National Health Insurance Act or 2013.
Management of both hospitals, however, said the problem lies with state health insurance agency, particularly when it comes to RTH claims.
“Some of the RTH are results of untimely and ever changing (revisions) in the existing circular and policies issued by the PhilHealth,” the Lung Center said in its comment to the audit team.
A similar observation was submitted by the PCMC.
“The PCMC strictly follows the guidelines prescribed by the RIRR of RA No. 7875, as amended, and other relevant PhilHealth Circulars. However, despite their efforts, the reasons of denied and RTH claims are beyond the control of PCMC and rest solely to the discretion of PhilHealth reviewers and constant change of guidelines and requirements implemented by PhilHealth,” the hospital said in its explanation to the COA.
Auditors noted that denied and RTH claims representing uncollected accounts have accumulated for both hospitals, representing loss of income.
They pointed out that the P251.534 million for LCP and P25.7 million for PCMC are substantial losses that could have been used to augment their funding for the upgrade of facilities, equipment, and services.
While RTH claims are theoretically appealable to PhilHealth, the COA noted that there is no assurance that said appeal will be granted, the audit team explained.
“Under the PhilHealth rules, claims denied/returned to hospitals can no longer be collected from the concerned patients,” it added.
At best, all the hospitals can do is to keep on improving their evaluation processes to ensure completeness and accuracy of data before the claims are submitted to PhilHealth — all while trying to beat deadline of submission.
The Lung Center said it has been doing its best to comply even if the procedure requires a lot of coordination with various departments.
“Part of the processing of the claims is the meticulous final review as to the completeness and correct data of claims for submission and continuous coordination with the clinical services, doctor, nurses, diagnostic personnel and medical records to help in order to perfect each claim,” the hospital said.
