MANILA, Philippines – The Philippine Health Insurance Corporation (PhilHealth) returned P243 million in claims filed by the National Kidney and Transplant Institute (NKTI) between 2021 and 2022 due to insufficient documentation, state auditors reported.

The amount of claims temporarily rejected by the state health insurer represented a spike of 382.8% from a year before.

“Claims for reimbursement…were returned to hospital and denied due to non-compliance with the documentary requirements and conditions provided under the revised Implementing Rules and Regulations of Republic Act No. 7875 or the National Health Insurance Act of 2013,” the Commission on Audit (COA) said.
 
COA noted that the NKTI personnel refiled 59,630 out of 60,830 return-to-hospital (RTH) cases or cases sent back to the hospital to redo.

Meanwhile, the speciality hospital refiled 8,888 out of 8,958 denied claims.
 
At least 1,200 claims for refiling are pending as of the end of 2022, for appeal with PhilHealth.

Must Read

CA to medical practitioners: Don’t engage in unethical practices to dupe PhilHealth

Among the reasons for the returns were:

• Discrepancies or incomplete data (the usual grounds cited for the returns)
• Confinement for less than 24 hours
• The doctor was not PhilHealth-accredited.
• The cases were not eligible for compensation.

NKTI assured auditors that its staff filed the claims in good faith, but that the denials were “beyond their control.”

NKTI also complained about PhilHealth’s frequently changing guidelines and requirements.

They noted that requirements sometimes changed as claims were being processed.

“These numbers speak volumes [about the] commitment to minimize, if not eliminate, cases of RTH and denied claims,” the COA said.

State auditors said the compounding uncollected accounts from PhilHealth could end up becoming income loss for NKTI, funds that could be used to augment operations costs to fund improvement of its facilities.

The hospital management said its billing and claims division is stepping up its coordination with the state health insurance to improve its income. – Rappler.com