Hospitals did not give P535M worth of senior discounts in 2022 – COA

MANILA, Philippines – The Commission on Audit (COA) said several healthcare institutions in seven regions did not give senior citizen discounts for a total of 196,695 cases, with the amount of undeducted discounts totaling P535.626 million.

“In PRO (PhilHealth Regional Offices) NCR and Rizal, IV-B, V, VI, VII, IX, and XI, discrepancies in the computation, deduction, and charging of mandatory senior citizen discounts from the actual hospital charges, including professional fees, for [senior citizen] member-patients resulted in overpayments in the total amount of P535.626 million,” the COA said in its 2022 audit report on the Philippine Health Insurance Corporation (PhilHealth).

State auditors checked all benefit claims paid by PhilHealth from January 1 to December 31, 2022, and found that the agency shouldered P113.1 million of the discounts that were not deducted from the total actual hospital charges, including professional fees.

The remaining P422.526 million were paid by the senior citizens themselves or by other government agencies extending medical assistance, such as local government units, the Office of the President, the Department of Social Welfare and Development, and the Philippine Charity Sweepstakes Office.

While the report did not name the healthcare institutions involved, it said most of these cases were found in the National Capital Region/Rizal (106,630 claims), followed by Central Visayas (50,392 claims), Davao Region (35,896 claims), Zamboanga Peninsula (3,078 claims), Western Visayas (538 claims), Mimaropa (117 claims), and Bicol Region (44 cases).

According to the PRO NCR and Rizal, they primarily relied on figures, particularly the discount information in the statement of account “as they lack direct authority over [healthcare institutions] to monitor and ensure the proper implementation of the relevant provisions for the benefits and privileges” that senior citizens are entitled to under Republic Act No. 9994 or the Expanded Senior Citizens Act of 2010.

“As a result, claims are processed and reimbursed without recomputing the accuracy of the applied discounts,” the auditors said, noting that “PhilHealth should have established controls to ensure that adjudicators validated the proper deductions to avoid overpayment of claims to [healthcare institutions].”

The COA added: “In the absence of such controls, [senior citizens], as PhilHealth member-patients, were deprived of the full benefits of the discounts and were compelled to pay outstanding balances out of pocket. Additionally, PhilHealth and other government agencies offering health insurance and medical assistance incurred unnecessary expenses, while [healthcare institutions] benefited from the overpayments.”

With the excess payments, the auditors said PhilHealth also incurred losses as the funds could have been used for other benefit claims.

Aside from establishing sufficient controls, the COA recommended that the PhilHealth regional offices involved “strategize and intensify efforts” to recover overpayments of benefit claims to minimize the losses and ensure that their resources are used efficiently.

The COA said that during the audit exit conference last June 29, PhilHealth had already directed all its regional offices to “diligently comply” with the application of senior citizen discounts in all processed claims. – Rappler.com