The Philhealth Electronic Claims System

 (This is a preamble to another blog where I gave suggestions on improvements that can be made to Philhealth's IT system)

Philhealth is a health insurance corporation created by law in 1995 to purchase health services for its members - the Filipino people.

How does health insurance work?

There are at least three entities in a health insurance system - the payor, the provider, and the patient (sometimes also called a "member").

The concept is risk pooling. Without health insurance, the patient has to pay for his/her healthcare expenses out of his/her own pocket. For many Filipinos, getting hospitalized can easily bring them to bankruptcy when the hospital costs exceed their incomes. But in a given year, only a portion of a population actually needs hospitalization. The majority of the citizens remain healthy and do not get sick enough to be confined. 

Enter health insurance.

By remitting a regular premium to an insurance agency like Philhealth, members can now avail of benefits (such as coverage of their expenses during hospitalization). But this will only work if: all Filipinos regularly pay a premium and the cost of hospital care is controlled. Philhealth is the agency that collects these premiums and also pays for the hospital costs. By making sure the premium payments are collected, Philhealth is able to maintain a shared "insurance fund". By making sure the hospital costs are controlled and not excessive, Philhealth is able to distribute the fund to those who need it. By making sure the hospitals and the health professionals (collectively known as providers) are competent, Philhealth is able to ensure the best outcomes for the members.

In an ideal environment, all citizens regularly pay a premium and all their health expenses are covered. This is traditionally called "universal health coverage".

How will the hospitals and doctors get paid?

First, the hospitals need to be accredited by Philhealth. In this accreditation process, Philhealth makes sure the hospitals are properly equipped to provide care. Doctors also undergo their own accreditation. Aside from being licensed by the Philippine Regulatory Commission (PRC), doctors also pay their membership fees and also provider accreditation fees. 

Second, the providers need to file a claim. When a member gets hospitalized, the providers make sure the best possible care is given to the patient. And then upon discharge when the care is complete, the hospital files a claim.

What is inside a claim?

Quite a number of data but essentially a claim contains details about the patient, about the confinement such as diagnosis and interventions or procedures, and other data to justify the reimbursement of costs to the providers. Note the word "reimbursement" -- this is because the hospital has "advanced" the cost of care (room rate, doctors professional fees, tests, medicines, etc) and are now asking for payment after the discharge.

For Philhealth, a claim contains: CF1 (patient's proof of premium payments), CF2 (summary of the care provided to the patient), CF3 (a simple record of the mother and baby's care). Prior to 2012, these claims were submitted on paper and were processed by human adjudicators.

What is electronic claims?

At the outset, Philhealth already had an internal computerized system for processing the claims it receives. But since the claims submitted by hospitals were on paper, an army of encoders had to type in the details of CF1, CF2, and CF3 into this internal claims system. By 2009, Philhealth Information Technology Management Department began defining the standards needed for hospitals to submit the claims in electronic format. This was called electronic claims or eClaims. The benefits of eClaims were: efficiency, transparency, and auditability. With eClaims, it will be possible to perform three major functions - checking eligibility, submitting the claim, and tracking the status of the claim.

What is CF4? 

In 2019, Philhealth required an additional form called CF4. CF4 contained more detailed data such as courses in the wards, laboratory tests and results, radiology tests and results, medications, and their prices. For hospitals with electronic systems, these data were available but required transformation to fit the Philhealth standard. For hospitals without software, they had to hire encoders and acquire the services of a health information technology provider (HITP) to encode their data and submit it to Philhealth.