BACKGROUND: The Philippine Health Insurance Corporation (PhilHealth) has adopted several computer-based systems to enhance claims processing for hospitals.

OBJECTIVES: This study sought to determine the efficiency gains in the processing of PhilHealth claims following the introduction of computer-based processing systems, taking into account differences in hospital characteristics.

METHODS: Data were obtained from a survey conducted among 200 hospitals, and their corresponding 2014 claims figures as provided by PhilHealth. Summary descriptive statistics of hospital capacities (ownership, service level, and utilization of PhilHealth computer systems) and claims outcomes (claims rejection rates, as well as length of claims processing times for hospitals and with PhilHealth) were generated. Multivariate regression analysis was done using claims outcomes as dependent variables, and hospital capacities as independent variables.

RESULTS: Nearly a quarter of the surveyed hospitals did not utilize any of PhilHealth's computer-based claims systems. Utilization was lowest for primary as well as public facilities. Among those that used the systems, most employed the on-line membership verification program. The mean claims rejection rate was 3.81%. Claims processing by hospitals took an average of 35 days, while PhilHealth required 40 days from receipt of claims to the release of reimbursement. Regression analysis indicated that facilities that utilized computers, as well as private hospitals, had significantly lower claims rejection rates (p<0.05). The claims processing duration was significantly shorter among private facilities.

CONCLUSIONS: Private hospitals are able to process claims and obtain reimbursements faster than public facilities, regardless of the use of PhilHealth's computer-based systems. PhilHealth and public hospitals need to optimize claims processing arrangements.

Human ; Insurance Claim Review ; Philippines

Background: In the continuity of care, family and community physicians take into consideration patient insurance coverage, especially for those who require higher levels of care. The Philippine Health Insurance Corporation (PhilHealth) has had its electronic reimbursement claims processing since 2011 but the utilization of this system by hospitals may be affected by delays in claims reimbursement. Factors associated with such delays warrant further investigation. Objectives: This study aimed to determine the perceived factors by concerned hospital staff that affect delays in PhilHealth’s electronic claims processing system. Methods: Three focus group discussions (FGDs) were conducted using a predetermined set of questions. The hospitals were selected from respondents of a survey of a bigger study on the applicability of PhilHealth’s electronic claims processing. Each FGD involved eight-to-ten participants, mostly PhilHealth officers or information technology personnel from different hospitals covering Luzon, Visayas, and Mindanao. The hospitals were of different types/levels and included both government-run and privately-owned. Results: Factors affecting delays in electronic claims reimbursement are intrinsic to the hospitals’ operations, with delays in obtaining the physician’s signature as the most common cause. Accessing PhilHealth’s server was another major factor and was aggravated by problems in clarifying patient eligibility, non-updated data, and variations in the emphasis of regional evaluators. Hospitals within the national capital region and those using their own electronic medical records and health information system had better experiences with the electronic claims reimbursement. Conclusions The main factors affecting delays in electronic claims reimbursement among hospitals are associated with the hospitals’ institutional processes. The active participation of family physicians and primary care providers can help address these issues and subsequently improve service delivery, PhilHealth utilization, and overall patient satisfaction.
Electronics ; Humans ; Surveys and Questionnaires