COA sa DOH: P1.3B claims ng mga ospital na tinabla ng PhilHealth resolbahin

MANILA, Philippines- Inatasan ng Commission on Audit (COA) ang Department of Health (DOH) na madaliin ang koleksyon na tinanggihan at ibinalik na reimbursement claims ng mga ospital na nagkakahalaga ng mahigit sa P1 bilyon mula sa Philippine Health Insurance Corporation (PhilHealth).

Makikita sa 2023 annual audit report ng COA na ang claims ng government hospitals ay umabot na sa P595,563,644.12 na “denied for reimbursement” naman ng PhilHealth habang ang isa pang P733,460,070.67 na tinukoy bilang RTH o returned to hospital dahil sa non-compliance sa probisyon ng Republic Act No. 7875 o batas na lumikha ng state-run health insurer.

Naobserbahan din ng audit team ang non-compliance kaugnay ng PhilHealth issuances.

Tinukoy ng COA ang Section 38, Article VIII ng Republic Act No. 7875, na nagsasaad na: “PhilHealth may deny or reduce payment of claims if they have false or correct information and when the claimant fails to comply with the rules of the law.”

Tinukoy din nito ang Section 47 ng binagong implementing rules and regulations (RIRR) at batas na nagsasabing “denied claims shall not be recovered from the member.”

Sinabi ng COA na ang “denied and returned claims” ay nagresulta ng loss of income ng mga ospital.

“The amount of P595,563,644.12 is a significant loss of income as it could have been used to augment its fund requirements for operation and improving the existing hospital facilities,” ayon sa COA.

“The returned claims amounting to P733,460,070.67, which are recognized as receivables by the concerned operating units, exposed them as vulnerable to possible loss of income,” dagdag na pahayag ng ahensya.

Ang mga karaniwang sanhi para sa denied and returned claims ay ang:

• “Absence/loss of records to support long outstanding claims
• Improperly accomplished statement of account and/or claim signature form
• Incomplete/non-compliance with documentary requirements
• Inconsistencies between encoded forms and data in attachments
• Case was not compensable or exhausted compensable days or allowed number of claims for the illness/procedure was reached
• Filing of claims beyond the statutory period
• Violation of single-period confinement
• Lapses in the PhilHealth system and constant change of guidelines and requirements
• Non-compliance to minimum standard of care per patient.”

“The lapses relative to the preparation and filing of the hospital’s claims from PhilHealth would make an impression that certain policies and procedures were not duly observed, particularly in ensuring that claims are completely supported with required documents appropriately filled up, resulting in the return of filed claims,” ang sinabi ng Komisyon.

Ang mga rehiyon na may ‘denied and returned claims’ sa mga ospital ay ang National Capital Region, Cordillera Administrative Region, Central Luzon, CALABARZON, Northern Mindanao, Davao Region at SOCCSKSARGEN.

Ang Southern Philippines Medical Center (SPMC) sa Davao City ang nangunguna sa listahan para sa ‘denied and returned claims’ na may 406.64 million at P353.56 million bawat isa.

Pumangalawa naman ang Mayor Hilarion A. Ramiro Sr. Medical Center sa Ozamiz City na may pinakamataas na halaga ng ‘denied claims’ na P93.24 million, subalit walang anumang ‘returned claims.’

Ang Jose B. Lingad Memorial General Hospital sa San Fernando, Pampanga ay mayroong ‘returned claims’ na nagkakahalaga ng P295 million at ang ‘denied claims’ ay nagkakahalaga naman ng P19.84 million.

Napagkasunduan naman ng COA at Health Secretary na atasan ang mga pinuno ng mga concerned hospitals na “make representations to the PhilHealth to determine the status of the receivable therefrom and inquire on the courses of actions that can be done to facilitate collection.”

Ang isa pang audit recommendation na sinang-ayunan ay ang pagtatatag ng hospital policies na mag-aaral sa mga kinauukulang division para pagsamahin ang “balances, settlement at monitoring ng denied at returned PhilHealth claims.”

Bilang tugon sinabi ng DOH na mayroong “continuous reconciliation” na isinasagawa ang Accounting and Billing Unit with PhilHealth sa pamamagitan ng circular. Nagbigay din ang ahensya ng “refresher training on filing of claims to PhilHealth claims processors” para i-rehash ang “accuracy” ng impormasyon ng miyembro o pasyente.

“Management claimed that denial is not a loss of revenue and that there is a huge disparity between the receivables computation of DOH offices and PhilHealth. Round table discussions were held for the reconciliation of receivables,” ang sinabi sa report.

“The management remains committed to compliant filing, document submission, and timely claim processing to avoid RTH and denied claims, with on-going efforts to facilitate reconsideration of eligible claims by PhilHealth,” dagdag pa. Kris Jose