Philippine Children’s Medical Center unable to refund P200-M COVID-19 swab tests

MANILA, Philippines – The  Philippine Children’s Medical Center (PCMC) stands to absorb losses of over P200 million because it could not claim for reimbursement from the Philippine Health Insurance Corporation (PhilHealth) for COVID-19 swab tests taken by arriving overseas Filipino workers (OFWs) during the height of the pandemic.

It was PCMC which handled the laboratory works of the reverse transcription polymerase chain reaction (RT-PCR) swab tests administered to over 100,000 inbound OFWs from 2021 to 2022.

However, though the Commission on Audit raised the alarm on the possible multi-million losses of the public hospital, the state auditors said the PCMC was not solely to blame for the reimbursement problems.

COA said Philippine Coast Guard (PCG) was to blame for the dire situation of PCMC.

It was the PCG which collected the specimen samples of arriving OFWs. But to date, PCG has not provided the documents needed by PCMC for it to get a refund from PhilHealth. 

As the pandemic raged and more OFWs returned home, the PCG was assigned to take their swab specimens. A Department of Health memorandum on March 23, 2021 signed by the assistant secretary of the Public Health Services Team assigned PCMC to process the specimens of OFWs.

The same memorandum said PCMC could reimburse the costs of the swab tests as these were included in the PhilHealth benefit package issued during the pandemic as stated in PhilHealth Circulars No. 2021-001 and 2021-0021.

“Inquiry with the personnel from the COVID-19 laboratory and Billing and Claims Division revealed that the 62,285 claims with an aggregate amount of P200.277 million which were not filed for reimbursement with PhilHealth was due to the lack of necessary supporting documents for the RT-PCR test,” the COA team said.

All in all, the PCG collected 101,333 specimens from OFWs from 2021 and 2022. These were processed by the PCMC laboratory with a total cost of P328.544 million.

PCMC records show that 39,048 claims with a billing cost of P128.268 million were transmitted to PhilHealth. However, only 24,002 were actually paid for an amount of P81.72 million.

PCMC’s billing and claims division said it did not forward to Philhealth the remaining 61,248 claims from 2021 worth P197.373 million, and 1,037 claims from 2022 worth P2.904 million because of lack of documentation.

“According to the COVID-19 laboratory, the required supporting documents and information for PhilHealth claim reimbursement should emanate from PCG and/or One Stop Shop for the Management of Returning Overseas Filipino (MROF) since they were responsible for the gathering of information from the OFWs at the time of collection of specimen for swabbing,” COA said.

Among the problems identified were: 

• unreadable file/claim forms downloaded from PCG system/ platform; 
• unrecovered files/claim forms from PCG due to high volume of data resulting in software/system glitches; 
• claims with no PhilHealth identification number/multiple PIN or undeclared dependent; 
• and insufficient information on the case investigation forms.

COA noted that section V.B of PhilHealth Circular No. 2021-0021 said it was the PCG/One Stop Shop that should “ensure that the documents needing information from the OFWs are completely filled-out and forwarded to the testing laboratory.”

Faced with thousands of unprocessed claims last year, the PCMC executive director asked for the help of the Management of Returning Overseas Filipino (MROF) under the National Task Force Against COVID-19 and the head of the One Stop Shop.

Compounding PCMC woes was the tight deadline to file claims. Philhealth does not process or release reimbursements  which have not submitted the required documents within 120 days from the date of the swab tests.

However, as of January 12, 2023, the PhilHealth Regional Office (PRO) NCR-Central Branch informed  PCMC that in case it could not produce required documents, the public hospital may instead get a certification from the PCG on the number of swab test processed by the COVID-19 laboratory. – Rappler.com