COA tells DOH to fix system as it notes PhilHealth denial of P111.1 million in claims

MANILA, Philippines — The Commission on Audit (COA) has called the attention of the Department of Health (DOH) over the rejection of P111.1 million in reimbursement claims filed by public hospitals at the Philippine Health Insurance Corp. (PhilHealth).

“Owing to the Hospitals’ inability to address the recurring challenges and non-compliance with applicable regulations, claims for reimbursement to the PHIC [PhilHealth] in the aggregate amount of ₱111.150 million were denied,” COA said in its report.

“This condition has resulted in the Hospitals’ loss of income which could have been used to augment their operating requirements,” it added.

As shown in a chart provided by COA, the bulk of the denied claims were made by the Dr. Jose N. Rodriguez Memorial Hospital (DJNRMH) — amounting to P63.14 million, or more than half of all the denied claims.

Next came the Cagayan Valley Medical Center with P7.534 million, Mayor Hilarion A. Ramiro Sr. Medical Center with P6.403 million, San Lorenzo Ruiz Women’s Hospital with P5.772 million, and the Culion Sanitarium with P5.241 million.

In terms of location, most of the hospitals whose claims were denied are in the National Capital Region (69 percent), followed by Cagayan Valley (12 percent), Ilocos Region and Northern Mindanao (6 percent each), and Soccsksargen (5 percent).

COA advised the DOH and the management of the hospitals to straighten out their policies and thoroughly review documents before being submitted to PhilHealth in order to improve its reimbursement rate.

COA also urged PhilHealth, currently riddled with corruption allegations, to talk with DOH officials to avoid the common recurrence of such incidents.

“We recommended and Management of the concerned DOH Hospitals agreed to […] analyze the causes for the disapproved/denied claims and make use such information in the processing of future PhilHealth claims to improve reimbursement rate,” COA explained.

“Further, we recommended that the DOH Management and the PHIC Board of Directors collaborate in instituting specific policies addressing the recurring problems on denied PHIC claims, specifically on improving the system showing the qualifications of claimants,” it added.

This developed as PhilHealth faced allegations that it had been paying claims based on fake medical conditions to certain health institutions they had partnered with.

Aside from issues concerning overpriced information technology items and illegal advance payments of COVID-19 funds to non-COVID treatment facilities, PhilHealth is also saddled with the accusation that it had been paying overpriced claims to some hospitals.

In 2019, the Philippine Daily Inquirer published an investigative report showing how PhilHealth was still paying dialysis claims even if the patients logged as receiving treatment were long dead.

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