The Philippine Health Insurance Corp. (PhilHealth) has denied a total of P71.17 million in claims made by the Philippine Heart Center (PHC) in 2020 due to its failure to comply with the National Health Insurance Act (NHIA).
In its 2020 audit report of the PHC released on Wednesday, the Commission on Audit (COA) said the state-run hospital failed to comply with the revised implementing rules and regulations of the NHIA, or Republic Act No. 7875, and PhilHealth circulars.
State auditors said claims that were denied and returned to hospital (RTH) led to the “accumulation of uncollectibles from PhilHeath and loss of income” for PHC.
“Based on the information provided by PhilHealth Regional Office, National Capital Region-Central, there were about 3,907 claims totaling P71.17 million for reimbursement of benefits submitted by PHC to PhilHealth that have been denied and returned to the center for the period Jan. 1, 2020, to Sept. 30, 2020,” the COA report read.
The agency said there were 2,432 denied claims, amounting to P38.919 million, and 1,475 RTH claims worth P32.25 million as of September 2020.
Invalid
According to PhilHealth Circular No. 2019-001, denied claims are those that have been “determined to be invalid and unworthy of payment/reimbursement due to absolute deficiency that cannot be remedied through RTH or due to a finding of an unmet requirement.
RTH is a “deficient claim after due adjudication and validation, redirected back to health-care institution with instructions to comply with certain requirements, but from which the action of returning the compiled claim to PhilHealth may result in the reversal of the deficiency into a good claim or noncompliance that may result into the denial of the claim.”
COA said RTH and denied claims were due to late filing; inconsistent and incomplete data; less than 24 hours confinement; case rate claim attended by nonaccredited physician; case not compensable; violation of single period confinement; claims forms not properly accomplished;and failure to submit readable claims online.
It said the P71.17 million increased the uncollectible receivables of PHC from PhilHealth, which could have been used to augment the requirement of the hospital for maintenance and other operating expenditures, such as repair of existing hospital facilities.