Health Maintenance Organizations (HMOs)

Planning Phase

Deliverable(s): Project Plan

Project Chapter

I. Background

HMO (Health Maintenance Organization) is a medical insurance group that provides health
services for a fixed annual fee for company's employees or individual. It is an organization that
provides or arranges manage care for health insurance, self-funded health care benefit plans,
individuals and entities.

 Accounting for HMO

HMO receives payment from their clients and classified it as "premiums". Payment varies depending
on the agreement and the packages availed by the clients. These premiums are used by the HMO to
pay the claims of the hospitals for health services used by the card holders. The excess in the
premiums over the cover period will consider as profit of the HMO. However, once the payment to
claims exceeds the premiums, the loss will offset by the excess in premiums of other clients.

 Disbursement

Once the card holder (client) admitted or used his benefit, the hospital will send a letter to the HMO
indicating that the client was admitted and avail a health service to them (also called as Claims). The
HMO will create a payable account to the hospital within 10 days and when payment will be made,
check voucher will be issued

II. Definition of the Problem

General Objective:

To develop a system for the disbursement cycle of Health Maintenance Organizations in accordance to
what were discussed in INFOTECH1

Specific Objectives:

 The system must be able to recognize which part of the cash outflows are recognized as part
of the disbursement system.
 The system must be able to process transactions that are disbursement-related and produce
the output that is needed by the end-users.
 III. Scope
 Logical Scope

The system will cover on how to account for the claims of the hospital for health services used by the
card holders and the other expenses that are recognized as part of the disbursement cycle of HMOs.

 Temporal Scope

The development of the system will start at the beginning of the semester until the date of submission.

 Organizational Scope

The Project Team

Name Designation
Arroyo, Angellic M. Project Head
De Guzman, Jessa E. Project Head
Agosto, Madelyn A. Financial Officer
Tatad, Mark Joshua S. Technical Specialist
Carolino, Dean Victor Technical Associate
Doca, Rico D.G. Technical Associate
Fetalcorin, Julie Jorraine Project Researcher
Binas, Czarina Kate S. Fieldworker

 Financial Scope
Cost-Benefit Analysis

Cost Benefit
Laptops Enables the development of the system
Serves as the storage media for work already
started
Applications/ Software Assist in elaborating the system to be
developed
Health Maintenance Organizations (HMOs)

Analysis Phase

Deliverable(s): System Requirements

System Requirements

I. Hardware/ Software Requirements

In-house or user developed – it is preferred to create own system for disbursement cycle of
HMO. It will be designed according to the end-user’s requirements.

II. End-user Requirements

(Disbursement Cycle)

1. Input (Raw Data)

2. Process
3. Output

a. PAYMENT REQUEST

A payment request, also known as a request for payment, is a nonstandard request by a

department for approval of payment by the company for goods or services. In the case of HMOs,
payment request is given by the hospital or other medical provider to the HMOs to request for
payment for their services. Requests for payment are used to gain approval for payment or in
some instances to provide reimbursement for a payment. Organizations that have payment
request processes use paper or electronic forms. Payment request given by the hospital to the
HMO normally includes 4 parts. First is the instruction where you can found the details about
the purpose of the payment request and the contact details of the medical provider. Next part is
the patients information and to be followed by the health care expenses. Health care expenses
shows the necessary dates, name of the physician or doctor, types of services provided to the
patient and the last part is the amount requested. The last part of a common payment request
form is the supporting documentations, it includes the proper certification and the signatures of
the person involved. The HMOs will review the PR Form to check if they can soon issue a check
voucher for the payment of the health services given to their client.

To summarize, it contains the following:

 Key dates
  Payment details and purpose

 Payment amounts

 Instruction about the purpose of the Payment Request

 Contact details of the medical provider

 Patients Information

 Health care expenses

 Name of physician/ doctor

 Type of services provided to the patient

 Amount requested

 Supporting documents

 Certifications and signatures

GENERAL PROCESS FLOW

Payment Confirmaion
and review of Check
Request the PR FORM voucher

INPUT PROCESS OUTPUT

b. PAYROLL

Payroll is the sum of all compensation a business must pay to its employees for a set period
or on a given date. It is usually managed by the accounting department of a business; small-
business payrolls may be handled directly by the owner or an associate. Payroll can also refer to the
list of employees of a business and the amount of compensation due to each of them. It is a major
expense for most businesses and is almost always deductible as such. Payroll can differ from one
pay period to another due to overtime, sick pay and other variables.

Information about Payroll:

 Employee Number
 Tax Status
 Rate Daily
 Basic Pay
 Overtime
 Gross Pay
 Withholding Tax
 SSS
 HDMF
 PHIC
 HMO Deductions
 Net Salary (Accrued Payroll)

GENERAL PROCESS FLOW

 START

Set Employee < -

First Employee

NO
Employee
Exists?

YES

Set Hours = Worked

Hours (Employee, Last
Period)

NO
Hours > 40?

YES

Set Overtime = Hours-40 Set Overtime = 0

Set Hours = Hours + Overtime

*

Set Salary = Hourly Rate

(Employee, Hour) * Hours

Print Cheque
(Employee, Salary)

Set Employee = Next Employee

END
 REQUIREMENT IN INFOTECH 2

ACCOUNTING INFORMATION SYSTEMS:

HEALTH MAINTENANCE ORGANIZATIONS

(DISBURSEMENT CYCLE)

PLANNING AND ANALYSIS PHASE

Prepared by

Arroyo, Angellic M.

De Guzman, Jessa E.

Tatad, Mark Joshua S.

Agosto, Madelyn A.

Biñas, Czarina Kate S.

Carolino Dean Victor

Doca, Rico D.G.

Fetalcorin, Julie Jorraine

CBET 01 801 E

For:
Mr. Keaster Diaz

Instructor

December 3, 2016