Exist sponsors forum for hospital CIOs, PhilHealth and HMO executives to discuss PhilHealth's eClaims project, challenges, and opportunities for collaboration towards improved healthcare services delivery in the Philippines.

1. ChatRoom Sponsored by:
Enabling Better Healthcare Delivery
BY MACEL LEGASPI
I
N 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, becausereconciliationofvitalinformationbetween well as for the hospitals,” said Arnie Dantis, Vice
the CEWS will allow a hospital (or any accredited the patient’s claim form versus PhilHealth’s President for Operations & IT Head at Asalus
healthcareprovider)tovalidateapatient’smember database has been streamlined via real-time claim Corporation, or IntelliCare.
registration and contributions with PhilHealth eligibility verification.” What’s more practical is when PhilHealth
immediately, thereby “reducing turnaround time “When a hospital finally submits the implements online verification upon admission
in eligibility verification as well as reducing the reimbursement claim papers with PhilHealth, -- when the patient checks in at the Emergency
number of return-to-hospital (RTH) claims.” the possibility of such documents returned to Room. When a patient is found to be ineligible
There are 70 or thereabouts private and the hospital is minimized or sometimes, even to receive insurance benefits at this instant, the
government hospitals signed up as part of the eliminated,” Bacallan confirmed. patient (or the immediate family of the patient)
pilot. Some of the hospitals that have completed Amazingly, however, even while the CEWS can straightaway rectify the issue, or at least try
the pilot run and currently utilizing the said web has proven success with its pilot, many healthcare to, instead of dealing with such inconveniences
service include St. Luke’s Medical Center, The intricacies are still stuck in the snail mail age. during discharge.
Medical City, Cardinal Santos Medical Center, the Philippines, Dominador Tacsuan, PhilHealth Organized by Computerworld Philippines claim reimbursement,” said Bacallan. “The However,thePhilippinegovernmentthrough
and Chinese General Hospital Medical Center. SeniorSocialInsuranceOfficeracknowledgedthat and sponsored by Exist and HP, the Chat Room hospital loses money from these un-reimbursable LESS PAPER AND BETTER the Commission on Audit still requires that
Lorma Medical Center (La Union), Bautista PhilHealth’scampaigntoreshapemanualtoonline gathered PhilHealth representatives, CIOs from claims. However, if possible, the hospital may WORKFLOWS PhilHealth forms be signed by the member (and
Hospital (Cavite), and Divine Word Hospital transactions shows no signs of slowing. “We are metro hospitals, and IT leaders of communicate with the discharged patient, re-try “If PhilHealth can implement an electronic the healthcare provider) even with an electronic
(Tacloban) are some of the hospitals outside the set to implement Electronic Claims Submission health maintenance organizations (HMOs) tocompletetheneededinformation,andre-filethe card that can be swiped through or tagged onto system in place.
National Capital Region which have also passed (phase2)andClaimStatusVerification/Payment to discuss and exchange ideas towards building an claim so that it can get its money back.” a machine and then be able to retrieve data so Certainly, this doesn’t help at all. In some
the pilot stage. (phase 3) quite soon. In fact, phase 2 is well ready ecosystem to enable better healthcare services for “The e-Claims system of PhilHealth -- that members do not have to fill up paper-based instances,thepatientsaren’tevencapableofmoving
At Computerworld Philippines’ follow up as it is already part of the CEWS’ installation kit,” the Philippine market. specificallytheCEWS--minimizesRTHincidents forms, it would make things easier for patients as their arms to accomplish this undertaking. The
chat room session on IT-Enabling Healthcare in Tacsuan announced.
RETURN-TO-WHAT?
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 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 are 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
22 COMPUTERWORLD PHILIPPINES FEBRUARY 2012 www.computerworld.com.ph 23

2. CHATROOM Enabling Better Healthcare Delivery
immediate family member who’s running around PhilHealth members. If there is a confinement, Mike Muin, MD and CIO of The Medical
thehospitalthenbecomesevenmoreantagonized the member files for PhilHealth benefits and the City questions if the HMOs really need to see the
-- knowing he [she] has to get a decent signature hospital bills the HMO net of the PhilHealth patient’schartormedicalrecords.“Isitappropriate
and come back to the long line at the checkout portion of the confinement. If there is excess to share the diagnostics to the HMOs?”
service station. from this amount, the refund should go to the It’s probably meritorious from an audit
Consider if the online system can check the HMO because it was the one that paid for it standpoint because if the hospital finds out that
remaining balance of a member’s coverage. “The -- not the hospital, and neither the patient, who the patient is covered by an HMO, the hospital
patient must be prepared to dole out, in case the didn’t pay for anything. -- or the doctor has a tendency to run exorbitant
coverage has been exhausted,” said Irene Limpo, The more the HMO pays, the higher the tests, which essentially means HMOs would shell
MD, Vice President for Medical Services at premium to its clients. If they can obtain their out more money.
Philhealth Care, Inc. ARs effectively, then the premium will go low -- As these concerns become fleshed out,
“Itwouldbearelieffortherelativewho’sdoing this ultimately means more affordable healthcare the reality of a nationwide health information
the legwork [for the patient] if there was system for everyone. exchange starts to emerge. Hopefully soon, the
or if part of the system could validate member Call it shrewd but it’s not surprising for relationships between the stakeholders will shift
payment details and status,” said Carlos da Silva, hospitals to have patients who take advantage from one-off relationships with siloed systems to
Executive Director of the Association of Health of being confined just to earn from this that of an integrated framework that will make
Maintenance Organizations of the Philippines. mismanagement. data available for all stakeholders, anywhere and
“It eliminates the need to go to one’s HR head The idea of having a clearing house such anytime.
for a certification.” as what the banking industry currently utilizes
PhilHealthtogetherwithhealthcareproviders for its transactions is a good benchmark for CONCLUSION
and HMOs have to find ways to make it easy for HMOs and hospitals to look into. “Take a “Our problems here are not unique,”
patients to be treated with less paperwork. check, deposit it to your bank account, which noted Rapes, sharing that he has just attended
may not be the same bank where the check was a similar healthcare IT forum in the United
FIRST WAVE OF ELECTRONIC drawn, and you will get the cash once the check States. “I think there are lessons which we can
TRANSFORMATION has cleared. It is evident that technology is being take from America’s healthcare system -- from
Digitization has still a long way to go. The used to speed up as well as ensure the accuracy improving workflows to data integration, as
Philippine healthcare industry is entering its first of these transactions. If HMOs and hospitals well as from health reform to putting the right
wave of electronic transformation. But there are have some standardized process -- this model will tools in place. PhilHealth can take the lead by
challengeswithregardstoprivacy,interoperability, certainly make them more efficient,” remarked its sheer coverage. PhilHealth can be the de
and policy that need to be addressed. Jerry Rapes, CEO of Exist. facto standard.”
“Will the system resolve the issue regarding But speaking of clearinghouse, according PhilHealth has not been noteworthy for its
the wrong values billed to the HMOs by the to the hospitals: the HMOs must also work campaign to go electronic. But the opportunities
hospitals?” asked da Silva. “Not knowing how on standardization. “We’d like to be able to remain bright. “We’re working on a number of
much we have overpaid is a very pressing setback.” communicate to HMOs easily,” said Edison efforts [at PhilHealth] aimed at strengthening
“HMOs do not know how much they have Dungo, Head of Applications Development & our partnership with healthcare providers in
overpaid,” Dr. Limpo said. “The hospital, as a Maintenance Information Technology at Makati doing online transactions,” added Tacsuan.
general rule, will not return the balance, unless we Medical Center. With Eduardo Banzon, MD at the helm [of
ask for it. We cannot show any proof because we “We’ve initiated an online linkage with one PhilHealth], there are huge possibilities for
don’t have the documents to show -- the hospital or two HMOs but the lack of standardization is growth.
has this information.” hindering us from moving forward.” Electronic claims processing is just the tip of
Dr. Limpo added that the hospital’s system “From an IT standpoint, this can be enabled the iceberg. With increasing demand for access to
should at least interface or should have “electronic via a web service that interfaces between our healthcareamidstinadequatesupplyandresources,
visibility” with that of the HMOs’ to streamline systems,” commented Dantis. “Regardless of the ITisanenablerintransforminghealthcaredelivery
collection of account receivables (ARs). format that we have, you can access and download models in the Philippines.
“The information is all we’re asking for,” said information and vice versa.” “We’re very open to collaborating with
Nick Montoya Jr., MD, President of Medicard AccordingtoAHMOPIExecutiveDirector: HMOs, PhilHealth and other stakeholders
Philippines, Inc. HMOs can save a lot of time and there’s an ongoing effort among members of the towards improving our healthcare system,” said
money because they wouldn’t have to hire people organization to standardize not just data, but Don Rabanal, IT Director at Asian Hospital and
to routinely run after their lost monies. processestohelpimprovehealthcaredelivery.“We Medical Center. “We’re off to a good start with
And what of the PhilHealth circular that are for integrating [with the hospitals’ systems and PhilHealth’s eClaims project.”
dictatesthatHMOsdonotownthebalance?This with PhilHealth],” said da Silva.
conjures a bias in favor of the hospitals which gets On the other side, privacy competes with The above is a non-verbatim summary of Mediag8way’s
to keep the money. integration. Is the patient-doctor confidentiality free-flowing chat room session on “IT-Enabling
HMOs help make healthcare services clause a tenant or a law? Or is it an acceptable Healthcare in the Philippines” that took place last
more affordable as HMO rates are lower for practice bound by ethics? November 2011.
24 COMPUTERWORLD PHILIPPINES FEBRUARY 2012