In the hopes of making headway in the use of Information and Communication Technology (ICT) in the Philippine healthcare market, the Philippine Healthcare Insurance Corporation or PhilHealth launched October last year the first phase of its e-claims project dubbed the “Claims Eligibility Web Service” or CEWS. According to PhilHealth, the CEWS will allow a hospital (or any accredited healthcare provider) to validate a patient’s member registration and contributions with PhilHealth immediately, thereby “reducing turnaround time in eligibility verification as well as reducing the number of return-to-hospital (RTH) claims”.
There are 70 or thereabouts private and government hospitals signed up as part of the pilot. Some of the hospitals that have completed the pilot run and currently utilizing the said web service include St. Luke’s Medical Center, The Medical City, Cardinal Santos Medical Center, and Chinese General Hospital Medical Center. Lorma Medical Center (La Union), Bautista Hospital (Cavite), and Divine Word Hospital (Tacloban) are some of the hospitals outside the National Capital Region which have also passed the pilot stage.
At ComputerWorld Philippines’ follow up chat room session on IT-Enabling Healthcare in the Philippines, Dominador Tacsuan, PhilHealth Senior Social Insurance Officer acknowledged that PhilHealth’s campaign to reshape manual to online transactions shows no signs of slowing. “We are set to implement Electronic Claims Submission (phase 2) and Claim Status Verification / Payment (phase 3) quite soon. In fact, phase 2 is well ready as it is already part of the CEWS’ installation kit,” Tacsuan announced.
Convened by Exist, a software firm that develops enterprise healthcare applications with key clients in the local market, and HP, a renowned global technology company, the chat room gathered PhilHealth representatives, CIOs from metro hospitals, and IT leaders of health maintenance organizations (HMOs) to discuss and exchange ideas towards building an ecosystem to enable better healthcare services for the Philippine market.
After a patient has been discharged, the hospital files a set of claim forms to PhilHealth for the reimbursement of insurance deductions that were netted out from the patient’s bill.
“RTH happens when PhilHealth returns these forms to the hospital,” cited Allen Bacallan, VP and Chief Information Officer at Cardinal Santos Medical Center. “This means the information provided to PhilHealth is either lacking in detail or does not reconcile with PhilHealth’s database.”
If the patient is not updated in the payment of monthly dues, one’s membership status automatically becomes suspended. As such, the patient will not be able to claim insurance.
“With RTH documents, a hospital cannot claim reimbursement,” Bacallan said. “The hospital loses money from these un-reimbursable claims. However, if possible, the hospital may communicate with the discharged patient, re-try to complete the needed information, and re-file the claim so that it can get its money back.”
“The e-Claims system of PhilHealth — specifically the CEWS — minimizes RTH incidents because reconciliation of vital information between the patient’s claim form versus PhilHealth’s database has been streamlined via real-time claim eligibility verification.”
“When a hospital finally submits the reimbursement claim papers with PhilHealth, the possibility of such documents returned to the hospital is minimized or sometimes, even eliminated,” Bacallan confirmed.
Amazingly, however, even while the CEWS has proven success with its pilot, many healthcare intricacies are still stuck in the snail mail age.
Less Paper and Better Workflows
“If PhilHealth can implement an electronic card that can be swiped through or tagged onto a machine and then be able to retrieve data so that members do not have to fill up paper-based forms, it would make things easier for patients as well as for the hospitals,” said Arnie Dantis, Vice President for Operations & IT Head at Asalus Corporation, or IntelliCare.
What’s more practical is when PhilHealth implements online verification upon admission — when the patient checks in at the Emergency Room. When a patient is found to be ineligible to receive insurance benefits at this instant, the patient (or the immediate family of the patient) can straightaway rectify the issue, or at least try to, instead of dealing with such inconveniences during discharge.
However, the Philippine government through the Commission on Audit still requires that PhilHealth forms be signed by the member (and the healthcare provider) even with an electronic system in place.
Certainly, this doesn’t help at all. In some instances, the patients aren’t even capable of moving their arms to accomplish this undertaking. The immediate family member who’s running around the hospital then becomes even more antagonized — knowing he [she] has to get a decent signature and come back to the long line at the checkout service station.
Consider if the online system can check the remaining balance of a member’s coverage. “The patient must be prepared to dole out, in case the coverage has been exhausted,” said Irene Limpo, MD, Vice President for Medical Services at Philhealth Care, Inc.
“It would be a relief for the relative who’s doing the legwork [for the patient] if there was a system or if part of the system could validate member payment details and status,” said Carlos da Silva, Executive Director of the Association of Health Maintenance Organizations of the Philippines. “It eliminates the need to go to one’s HR head for a certification.”
PhilHealth together with healthcare providers and HMOs have to find ways to make it easy for patients to be treated with less paperwork.
First Wave of Electronic Transformation
Digitization has still a long way to go. The Philippine healthcare industry is entering its first wave of electronic transformation. But there are challenges with regards to privacy, interoperability, and policy that need to be addressed.
‘“Will the system resolve the issue regarding the wrong values billed to the HMOs by the hospitals?” asked da Silva. “Not knowing how much we have overpaid is a very pressing setback.”
“HMOs do not know how much they have overpaid,” Dr. Limpo said. “The hospital, as a general rule, will not return the balance, unless we ask for it. We cannot show any proof because we don’t have the documents to show — the hospital has this information.”
Dr. Limpo added that the hospital’s system should at least interface or should have “electronic visibility” with that of the HMOs’ to streamline the collection of account receivables (ARs).
“The information is all we’re asking for,” said Nick Montoya Jr., MD, President of Medicard Philippines, Inc. HMOs can save a lot of time and money because they wouldn’t have to hire people to routinely run after their lost monies.
And what of the PhilHealth circular that dictates that HMOs do not own the balance? This conjures a bias in favor of the hospitals which get to keep the money.
HMOs help make healthcare services more affordable as HMO rates are lower for PhilHealth members. If there is confinement, the member files for PhilHealth benefits, and the hospital bills the HMO net of the PhilHealth portion of the confinement. If there is excess from this amount, the refund should go to the HMO because it was the one that paid for it — not the hospital, and neither the patient, who didn’t pay for anything.
The more the HMO pays, the higher the premium to its clients. If they can obtain their ARs effectively, then the premium will go low — this ultimately means more affordable healthcare for everyone.
Call it shrewd but it’s not surprising for hospitals to have patients who take advantage of being confined just to earn from this mismanagement.
The idea of having a clearinghouse such as what the Banking & Finance industry currently utilizes for its transactions is a good benchmark for HMOs and hospitals to look into. “Take a check, deposit it to your bank account, which may not be the same bank where the check was drawn, and you will get the cash once the check has cleared. It is evident that technology is being used to speed up as well as ensure the accuracy of these transactions. If HMOs and hospitals have some standardized process — this model will certainly make them more efficient,” remarked Jerry Rapes, CEO of Exist.
“We’ve initiated an online linkage with one or two HMOs but the lack of standardization is hindering us from moving forward,” said Edison Dungo, Head of Applications Development & Maintenance Information Technology at Makati Medical Center.
“From an IT standpoint, this can be enabled via a web service that interfaces between our systems,” commented Dantis. “Regardless of the format that we have, you can access and download information and vice versa.”
According to AHMOPI Executive Director: there’s an ongoing effort among members of the organization to standardize not just data, but processes to help improve healthcare delivery. “We are for integrating [with the hospitals’ systems and with PhilHealth],” said da Silva.
On the other side, privacy competes with integration. Is the patient-doctor confidentiality clause a tenet or a law? Or is it an acceptable practice bound by ethics?
Mike Muin, MD and CIO of The Medical City questions if the HMOs really need to see the patient’s chart or medical records. “Is it appropriate to share the diagnostics with the HMOs?”
It’s probably meritorious from an audit standpoint because if the hospital finds out that the patient is covered by an HMO, the hospital — or the doctor has a tendency to run exorbitant tests, which essentially means HMOs would shell out more money.
As these concerns become fleshed out, the reality of a nationwide health information exchange starts to emerge. Hopefully soon, the relationships between the stakeholders will shift from one-off relationships with siloed systems to that of an integrated framework that will make data available for all stakeholders, anywhere and anytime.
“Our problems here are not unique,” noted Rapes, sharing that he has just attended similar healthcare IT forum in the United States. “I think there are lessons which we can take from America’s healthcare system — from improving workflows to data integration, as well as from health reform to put the right tools in place. PhilHealth can take the lead by its sheer coverage. PhilHealth can be the de facto standard.”
PhilHealth has not been noteworthy for its campaign to go electronic. But the opportunities remain bright. “We’re working on a number of efforts [at PhilHealth] aimed at strengthening our partnership with healthcare providers in doing online transactions,” added Tacsuan. With Eduardo Banzon, MD at the helm [of PhilHealth], there are huge possibilities for growth.
Electronic claims processing is just the tip of the iceberg. With an increasing demand for access to healthcare amidst inadequate supply and resources, IT is an enabler in transforming healthcare delivery models in the Philippines.
“We’re very open to collaborating with HMOs, PhilHealth and other stakeholders towards improving our healthcare system,” said Don Rabanal, IT Director at Asian Hospital and Medical Center. “We’re off to a good start with PhilHealth’s eClaims project.”
The above is a non-verbatim summary of Mediag8way’s free-flowing chat room session on “IT-Enabling Healthcare in the Philippines” that took place last November 2011. The article appeared in the February issue of ComputerWorld Philippines.