As the country’s largest health insurance provider and primary source of hospital funds, Philhealth can single-handedly affect healthcare policy changes unlike any other. Even as the Dept of Health struggles with handling the COVID 19 pandemic – the accuracy of reporting, recruiting, and empowering medical personnel not to mention managing its public persona, Philhealth has continued to stealthily move powerful care institutions to do its bidding with less fanfare.
This is not to say that resistance is non-existent. On the contrary, Philhealth is among the most difficult to please, for being quite unpredictable and dynamic as it responds to situations with its advisories via its circulars. One must understand that it is responsible for a huge amount of money. Leaving hospitals huffing and puffing with sudden policy changes and updates to ensure proper disbursements, claims and billing departments can only breathe a sigh of relief if their counterpart team of doctors, nurses, and other care providers are as flexible as their IT personnel.
Beginning in 2018, Philhealth has made and remade its eClaims system not just as the primary payment system for medical services but a valuable cross-checking clinical tool. It wouldn’t be surprising that as time passes, the eClaims will be requiring more and more supporting data in the form of clinical information that will be good enough to paint a picture of patient health statuses and clinical protocols for every medical condition.
What may initially be just diagnoses, the data in eClaims submitted by hospitals for their patients include procedures, medications, and other forms of treatment received. By being digital, cross-referencing the case rates with allowable treatment is now possible. One could surmise that the eClaims will not just offer proof but more importantly, ensure that globally-accepted, evidence-based clinical protocols were followed to approve the reimbursements.
In this scenario, hospital information systems will play a vital role in streamlining the process of eClaims processing. While doctors and care teams ensure that correct and minimally varied treatment protocol is followed in treating patients, they would also be looking to match these with case rates and requirements as well. With digital systems in place that store clinical data such as EMR, the eClaims reimbursement forms would then require minimal manual encoding and prevent literally, ‘costly’ errors.
If payment reimbursements are not enough reason to adopt better hospital IT systems and use of medical records instead of paper, then they will need to find other sources of revenue and prepare to suffer business consequences.
Once all things fall into place, patients would also get to benefit the most. With the requirements outlined in the eClaims, they get to receive the right treatment their condition requires and hopefully, the improved patient outcomes that healthcare institutions are primarily in existence for.
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