Disparities in hospital Capacities and Efficiency of Computer-based health insurance Claims Processing

  • Alvin B. Caballes
  • Gene A. Nisperos
  • Philip C. Zuniga
Keywords: administrative claims, healthcare electronic data processing, insurance claims processing, Philippines


Background. The Philippine Health Insurance Corporation (PhilHealth) has adopted several computer-based systems to enhance claims processing for hospitals.

Objectives. This study sought to determine the efficiency gains in the processing of PhilHealth claims following the introduction of computer-based processing systems, taking into account differences in hospital characteristics.

Methods. Data were obtained from a survey conducted among 200 hospitals, and their corresponding 2014 claims figures as provided by PhilHealth. Summary descriptive statistics of hospital capacities (ownership, service level, and utilization of PhilHealth computer systems) and claims outcomes (claims rejection rates, as well as length of claims processing times for hospitals and with PhilHealth) were generated. Multivariate regression analysis was done using claims outcomes as dependent variables, and hospital capacities as independent variables.

Results. Nearly a quarter of the surveyed hospitals did not utilize any of PhilHealth’s computer-based claims systems. Utilization was lowest for primary as well as public facilities. Among those that used the systems, most employed the on-line membership verification program. The mean claims rejection rate was 3.81%. Claims processing by hospitals took an average of 35 days, while PhilHealth required 40 days from receipt of claims to release of reimbursement. Regression analysis indicated that facilities which utilized computers as well as private hospitals had significantly lower claims rejection rates (p<0.05). The claims processing duration was significantly shorter among private facilities.

Conclusions. Private hospitals are able to process claims and obtain reimbursements faster than public facilities, regardless of the use of PhilHeath’s computer-based systems. PhilHealth and public hospitals need to optimize claims processing arrangements.


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