Metro Manila (CNN Philippines, July 7) — The Philippine Health Insurance (PhilHealth) Corporation has denied and returned to hospitals (RTH) a total of 949 claims for reimbursement worth ₱110 million to the Philippine Heart Center (PHC) last year due to lack of documents, according to the state auditors.
The latest report from the Commission on Audit (COA) said the denial of claims was because of non-compliance with the documentary requirements and conditions provided under the revised Implementing Rules and Regulations of National Health Insurance Act (NHIA) of 2013.
COA added that this has resulted in buildup of uncollectible accounts from PhilHealth and consequently loss of income to the PHC.
Out of the 949 claims, 253 (26.66%) were denied while 696 (73.34%) were RTH.
Under Section 47 of NHIA, the amount of claim shall not be recovered from the member when the claim is denied.
Below are the reasons for the denial and RTH claims:
– Discrepancies, inconsistencies, incomplete data, or other documents are not submitted
– Beyond the 45-day benefit limit policy
– Less than 24 hours confinement
– Case rate claim attended by a non-accredited physician
– Case is not compensable
– Actual charges are higher than all case rates policy
– Overlapping confinement
– Claim forms not properly accomplished
– Filed beyond 120 calendar days
– No required medical documents
According to state auditors, PHC’s Billing and Claims Division (BCD) is constantly monitoring denied and RTH claims.
\”The BCD averred that despite their efforts, the reasons for denied and RTH claims are beyond their control and rest solely to the discretion of PhilHealth adjudicators or evaluators,\” the report read.
It added that the management is actively pursuing collections from PhilHealth by filing motions for reconsideration on the denied claims.
The recent number of denied claims recorded in December 2022 is 3,265 lower compared to 4,214 in December 2021.
But notwithstanding the decrease, COA said the denied and RTH claims of ₱110.062 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.\”
