DOH told: Address P1.3-B denied, returned PhilHealth claims

The Commission on Audit (COA) has told the Department of Health (DOH) to explore all possible means to collect from the Philippine Health Insurance Corp. (PhilHealth) the denied and returned reimbursement claims of government hospitals which stood at P1.33 billion as of end of 2023.

- By ELIZABETH MARCELO

Based on the COA's 2023 annual audit report on the DOH released last Dec. 2, government hospitals' claims for reimbursement totaling P595.56 million were denied by PhilHealth due to noncompliance with the requirements prescribed under the revised implementing rules and regulations (RIRR) of Republic Act 7875 or the National Health Insurance Act (NHIA) and other related PhilHealth issuances.

The COA said there were also claims amounting to P733.46 million which were tagged as "RTH" or returned to hospitals.

The claims with incomplete supporting documents or erroneous entries are being returned by PhilHealth to the concerned hospitals to give them the chance to address the deficiencies.

The COA pointed out that under Section 47(f) of the RIRR of the NHIA, denied reimbursement claims shall not be recovered from the patients or PhilHealth members. Thus, the accumulation of denied reimbursement claims translates to income loss of government hospitals' operating units, adding that the huge amount of returned claims may also result in income loss if not addressed immediately.

"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," the COA said.