Electronic Claims Processing in the

Philippines: Is Change Coming Soon?

BOBBY A. CRISOSTOMO

Makati Shang-rila

September 15, 2016

• PhilHealth Circular No. 014, s. 2011 –

Implementation of Claims Eligibility Web

Services (Oct. 3, 2011)

• About 81 hospitals participated from Oct. 2011 to

May 2012

• 14 (18%) developed own information system

• 82% engaged with IT companies to provide

CEWS

Issuances for the

Implementation of e-Claims

• PhilHealth Circular No. 38, s. 2012 –Accreditation of Health Information Technology Provider (Aug. 8, 2012)

• 22 applicants submitted letters of intent

• 16 submitted the required documents + DOH

• 6 passed the pre-qualification and

conformance & compliance test

Issuances for the

Implementation of e-Claims

• PhilHealth Circular No. 021, s. 2014 –Guidelines for e-Claims System Simulation (Sept. 8, 2014)

• Part 1:7 participated and passed the simulation (Dec. 2014)

• Part 2: 6 participated and passed the simulation (2016)

Issuances for the Implementation of e-Claims

• PhilHealth Circular No. 2016-0016 – Full Implementation of the Electronic Claims System (May 18, 2016)• Regional Orientation on Electronic Medical

Records and the Electronic Claims System on August 18-19, 2016

• PhilHealth Corporate Order on the Implementing Guidelines on the Full Implementation of the Electronic Claims System (For signing)

Issuances for the

Implementation of e-Claims

The Role of a HITP

P.C. No. 038 series 2012 “Accreditation of Health Information Technology Providers”

passed rigorous conformance and compliance tests on PhilHealth standards

accredited to assist IHCP implement the eClaims System

• secure connection at points of electronic transmission of personal and health information

• act as conduit for electronic transactions on claim reimbursements

Normal Claims Processing and e-Claims

Challenges in the Implementation of e-Claims

• Time frame for HCIs to implement e-Claimso Speed of HITPs to recruit HCI to become eClaims

compliant

• The capacity/performance of the ICT infrastructure o Between HCIs and HITPs;

o Between HITPs and PhilHealth

• Cost of the provision of serviceo Some HCIs may not afford to subscribe

o The service charge of HITPs may be too high

Challenges in the Implementation

of e-Claims• Overlapping of HITP services

o Two or more HITPs may be serving one HCI

• Change in the political climate

o The President or the Congress decides to stop the

services of HITPs because of social issue

• Services provided to HCIs

o HCIs may not be satisfied with the e-Claims services

• Effect of the transition period

o Within PhilHealth

o Within HCI

Thank You!