The facade of Philippine Heart Center —PHOTO FROM PHC Facebook
The Philippine Health Insurance Corp. (PhilHealth) has rejected P110 million worth of reimbursement claims from the Philippine Heart Center (PHC) due to lack of supporting documents, the Commission on Audit (COA) has found.
The state audit agency said the denial or remand of 949 claims resulted in a spike in the uncollectible accounts of PhilHealth and a loss of income to PHC, both government corporations, according to the COA audit of the heart center.
Based on the state auditors’ data, there were 253 denied claims amounting to P27.579 million while those returned to hospital (RTH) were at 696, worth P82.48 million, making up 949 claims totaling P110.06 million.
The PhilHealth said the PHC claims were denied or returned because of discrepancies, inconsistencies, incomplete documents, lack of required medical documents, overlapping claims and claims for less than 24 hours of confinement, among others.
But the PHC billing and claims division argued that the reasons for the denial or return of the claims were “beyond their control.”
The hospital instead blamed the discretion of PhilHealth adjudicators and evaluators who processed the claims, lapses in the PhilHealth system, and the constant changes PhilHealth implemented in its guidelines and requirements.
But PHC is “constantly monitoring” all the denied and returned claims, and that they are “actively pursuing” collections from PhilHealth by filing motions for reconsideration on the denied claims.
‘Material loss of income’
The audit report also noted that the number of denied and returned claims already decreased from 4,214 in 2021 to 949 last year.
It also pointed out that many denied claims that were appealed since 2016 were favorably reconsidered by PhilHealth.
However, a loss is still a loss, according to the commission, and these losses could have been used to improve some facilities of the Heart Center.
“Notwithstanding the decrease, the denied and RTH claims of P110.062 million is still a material loss of income to the PHC, which could have been used to augment its funding requirements for operation and improve the existing hospital facilities,” the COA said.
The audit team then reiterated earlier recommendations that the PHC require its personnel to properly evaluate patients’ claims even before sending them to PhilHealth, which has its own evaluation and disbursement criteria.
They were also told to “explore all possible remedies” to get PhilHealth to reconsider the claims before writing them off as bad collectibles.
State auditors also advised PHC personnel to continue their regular reconciliation and coordination with PhilHealth on the unpaid claims, “considering that these represent a significant portion of the recorded receivables and income of the PHC.”