Factors affecting delays in PhilHealth electronic claims reimbursement among hospitals: An initial study

ABSTRACT

Background@#In the continuity of care, family and community physicians take into consideration patient insurance coverage, especially for those who require higher levels of care. The Philippine Health Insurance Corporation (PhilHealth) has had its electronic reimbursement claims processing since 2011 but the utilization of this system by hospitals may be affected by delays in claims reimbursement. Factors associated with such delays warrant further investigation.@*Objectives@#This study aimed to determine the perceived factors by concerned hospital staff that affect delays in PhilHealth’s electronic claims processing system.@*Methods@#Three focus group discussions (FGDs) were conducted using a predetermined set of questions. The hospitals were selected from respondents of a survey of a bigger study on the applicability of PhilHealth’s electronic claims processing. Each FGD involved eight-to-ten participants, mostly PhilHealth officers or information technology personnel from different hospitals covering Luzon, Visayas, and Mindanao. The hospitals were of different types/levels and included both government-run and privately-owned.@*Results@#Factors affecting delays in electronic claims reimbursement are intrinsic to the hospitals’ operations, with delays in obtaining the physician’s signature as the most common cause. Accessing PhilHealth’s server was another major factor and was aggravated by problems in clarifying patient eligibility, non-updated data, and variations in the emphasis of regional evaluators. Hospitals within the national capital region and those using their own electronic medical records and health information system had better experiences with the electronic claims reimbursement.@*Conclusions@#The main factors affecting delays in electronic claims reimbursement among hospitals are associated with the hospitals’ institutional processes. The active participation of family physicians and primary care providers can help address these issues and subsequently improve service delivery, PhilHealth utilization, and overall patient satisfaction.