COA flags PH Children's Medical Center for failing to process over P200 M reimbursement for COVID tests to PhilHealth

The Commission on Audit (COA) flagged state-run Philippine Children’s Medical Center (PCMC) over its failure to file reimbursement claims worth over P200 million for COVID-19 tests to the Philippine Health Insurance Corporation (PhilHealth) since 2021. 

Based on COA’s 2022 annual audit report on the PCMC, the state-run hospital failed to file P197,373,246 million worth of claims for PhilHealth reimbursement in 2021 and another P2,903,600 million in 2022.

“The PCMC was unable to claim reimbursement from PhilHealth aggregating P200.277 million for the Reverse Transcription Polymerase Chain Reaction (RT-PCR) test conducted by the Center’s COVID-19 Laboratory covering 62,285 samples from the OFWs (Overseas Filipino Workers) collected by Philippine Coast Guard (PCG) due to the lack of supporting documents from PCG which are required by PhilHealth for the filing of claims on benefit package for SARS-CoV-2 test," the COA said. 

"The non-reimbursement by PhilHealth of said claims may result in a significant loss on PCMC for the operational expenses incurred in the conduct of RT-PCR testing,” added COA.

State auditors, citing a report provided by the Billing and Claims Division, said among the reasons for the failure to file the claims include system glitches and lack of necessary patient information.

The delay in the processing of papers also had a major impact on the PCMC's failure to file for PhilHealth reimbursement.

“Consequently, the non-filing for reimbursement of the RT-PCR test within the prescribed period due to the issues encountered in securing the required documents and information may result in a significant loss on the part of PCMC for the operational expenses already incurred such as the salaries and professional fees of COVID-19 laboratory personnel as well as the test kits used in the conduct of the RT-PCR testing on the samples collected, swabbed, and transferred by PCG to PCMC,” said COA.

COA also said that it was only on May 12, 2022, that the PCMC Executive Director informed the National Task Force Against COVID-19  about the issues regarding the non-filing of claims for reimbursement to PhilHealth.

State auditors disclosed that in the recent meeting held last January 12 between PhilHealth officials and PCMC, the hospital was advised that instead of the submission of required documents, it may request for a certification from PCG on the number of accommodated samples processed and include the reasons for non-submission of said claims for reimbursement.

COA also said PCMC should file a Motion for Reconsideration with PhilHealth for the reimbursement and explore other possible means to collect the amount of P200.277 million from PhilHealth.

PCMC, for its part, said that they are now communicating with the Health department, DOH, PCG, OWWA, and PhilHealth to solve reimbursement issues.

“Coordination with the One Stop Shop in obtaining OFWs data has been worked out and converting them to CIFs is currently ongoing. Further, a Certification from PCG to be signed and attached to the MR for PCMC’s PhilHealth claim reimbursement is being done,” the PCMC said.

“The Center (PCMC) also requested a Board of Trustees (BOT) Resolution pertaining to PCMC’s reimbursement claims with PhilHealth to ease the requirements due to extraordinary times and in response to the government’s bid to contain the pandemic,” the PCMC added.

As a rejoinder, COA said it appreciates the PCMC’s efforts to file claims to PhilHealth for the RT-PCR test reimbursement and that full compliance with the recommendations will be monitored.  —VAL, GMA Integrated News