PhilHealth vows to improve processing claims

July 10, 2012 10:29 pm 

MANILA, July 10 — The Philippine Health Insurance Corporation (PhilHealth) has vowed to improve processing of claims by its partner-providers to better serve its members.

"The Corporation indeed recognizes that we need to do more. We are not happy with the current TAT (turn around time) level and percentage of claims beyond 60 days, and we won’t stop pushing until optimal levels are achieved,” said PhilHealth president and chief executive officer Dr.. Eduardo P. Banzon.

He said that issue of delayed claims payments or claims backlog has long been addressed by PhilHealth since late last year.

"Improvements were a result of the push for case payment, improved operational efficiencies, overtime work by staff, the deployment of PhilHealth CARES, and proactive training and coordination of the PhilHealth regional offices with their respective partner hospitals," Banzon said.

Banzon's goal is to improve efficiency of claims processing, as reflected by two relevant measures: the average Turn Around Time (TAT) for claims; and the percentage of submitted claims paid beyond 60 days. Our commitment has not changed.

In 2011, he said that PhilHealth conducted a reconciliation procedure with partner hospitals, wherein it was found that the so-called backlogs were actually mislabeled claims – the assumed receivables have already been denied by PhilHealth but were not tagged/recorded accordingly by the hospitals.

Banzon noted that it was never its intention to deceive stakeholders,” adding that "from these experiences, it is apparent that IT systems have to be improved from both PhilHealth’s and providers’ end.”

In 2011, he said that PhilHealth average number of claims was around 340,000 a month, but during this period, the TAT was more than 60 days, with less than half of our 20 claims processing centers or regional offices having TAT less than 60 days. As for the percentage of submitted claims beyond 60 days, 38 percent of the claims were paid beyond 60 days.

By the end of June 2012, TAT has decreased to 48 days, with 16 out of 20 claims processing centers or regional offices reporting a TAT of less than 60 days. The TAT for case rates is even lower at 46 days, Banzon said.

This trend has been consistent in ALL PhilHealth Regional Offices, not just in Regions V, VI and NCR South.

Banzon said that percentage of claims paid beyond 60 days, on the other hand, has been reduced to 26 percent for all claims, with the percentage paid beyond 60 days for case payment claims now down to 23 percent .

These developments took place despite the increase of the monthly number of claims from around 340,000 per month to around 450,000 claims per month.

He believes that a shift to all case rates and electronic claims processing are key to attain claims efficiency that everyone will be happy with."

“Reducing claims TAT is an impossible task if everything is on paper. We encourage our partner hospitals, especially Level 3 and 4 Hospitals, to go electronic and enroll in our e-claims system to speed up reimbursements,” Banzon said.

There are currently 80 hospitals connected to the e-claims eligibility check module and PhilHealth will mobilize all level 3 and 4 hospitals to do electronic claims submission by the end of 2012 which shall be the long-term solutions in addressing claims backlog. (PNA)



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