News article from by Mayen Jaymalin

     With the improvement of the claims processing systems of The Philippine Health Insurance Corporation (PhilHealth), the claims have significantly increased from 340,000 to 450,000/month. This improvement is largely a result of their shift from a manual processing system to an electronic one. Not only did this develop their efficiency and decreased delays in claims but it also provided convenience to the beneficiaries.

     To be familiar with the PhilHealth rules of claiming the benefits, they only deny claims filed beyond 60 days after the patient has been discharged from the hospital. Incomplete claims with requirements, inconsistencies with the members' claim data, which includes proofs of contribution, dependency, hospital billing, and other discrepancies, are factors that delay the processing of claims according to the reviews made by PhilHealth and the health care providers. Thus with the improvement of the claims system, these discrepancies are properly addressed because their records become more accurate. These little developments would provide a significant amount of exposure to the members, which is crucial to the introduction of the annuities market in the future. These small changes will greatly affect the future especially when the projections of the country’s population show the high possibility of a significant increase in the claiming of insurance benefits by the members.

     Though this new measure of electronic processing system provided a good impact on the beneficiaries, it would also be best if PhilHealth would address other serious problems such as the implementation of the CEWS or the Claims Eligibility We Service. Moreover, PhilHealth should work on reaching its target number of services mandated by the law in order to provide universal health coverage to all Filipinos because two years ago, it had only delivered health care services to 85% of its target, which according to the law is not universal.

Aguila, Philip
Bufi, Pamela
Dimaano, Lorylie
Roces, Lannie

7/20/2012 12:56:40 am

Hi! I'm not as familiar with claims, but this does interest me so I have a few more follow up questions if you don't mind:

How big of a percentage do claims form in terms of PhilHealth's cost structure? Is it significant in terms of hampering the company's profit generation such that this increase in claims that they have reported should greatly influence the company? Is there a benchmark for the optimal percentage/unit of collected claims?

Why do you say that CEWS is another serious problem? Is this in relation to its impact to annuities as well? Or is this problem segmented to health products only? If the company was able to deliver health services to 85% of its target, then how about annuities alone? What is the current status of delivering services to annuities?

Thank you!


Leave a Reply.