electronic claims processing in the philippines ... -...
TRANSCRIPT
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
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