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  • Claims Monitoring Proposal: Eamc Philhealth Claims Management Team April 25, 2022

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    Dreff Palaganas
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    The document proposes a claims monitoring system to maximize PhilHealth reimbursements for a growing hospital. It identifies key areas in the claims process including initial encounters, billing, accounting, cashier, and PhilHealth portal. There are inconsistencies in turnaround time tracking due to disparate data sources and formats. The proposals include creating a final standardized claims flowchart, integrating a monitoring system, lobbying PhilHealth to make their portal searchable by discharge date, and standardizing internal turnaround time tracking.

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    Claims Monitoring Presentation

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    The document proposes a claims monitoring system to maximize PhilHealth reimbursements for a growing hospital. It identifies key areas in the claims process including initial encounters, billing, accounting, cashier, and PhilHealth portal. There are inconsistencies in turnaround time tracking due to disparate data sources and formats. The proposals include creating a final standardized claims flowchart, integrating a monitoring system, lobbying PhilHealth to make their portal searchable by discharge date, and standardizing internal turnaround time tracking.

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    6 views14 pages

    Claims Monitoring Proposal: Eamc Philhealth Claims Management Team April 25, 2022

    Uploaded by

    Dreff Palaganas
    The document proposes a claims monitoring system to maximize PhilHealth reimbursements for a growing hospital. It identifies key areas in the claims process including initial encounters, billing, accounting, cashier, and PhilHealth portal. There are inconsistencies in turnaround time tracking due to disparate data sources and formats. The proposals include creating a final standardized claims flowchart, integrating a monitoring system, lobbying PhilHealth to make their portal searchable by discharge date, and standardizing internal turnaround time tracking.

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    © All Rights Reserved
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    of 14

    Claims Monitoring

    Proposal
    EAMC PhilHealth Claims Management
    Team
    April 25, 2022
    Introduction
    Monitoring of Status and Turn-
    around-time of Claims
    BACKGROUND

    Need to Maximize PHIC


    Reimbursements
    1,000-bed capacity by 2025, 1200-
    bed capacity by 2028-2030
    Standardization, Efficiency, and
    Ease of Process - SCALABILITY
    First Principles
    Trying to Identify the Flow of Information:
    Physical/Digital

    Where is it Located?

    What Information is Available?

    Who Needs Access?

    How is the Data Presented?


    First Principles
    Standardize the Flow of Information:

    SCALABLE

    CONSISTENT

    ACCESSIBLE

    SERVICEABLE
    Identifying Key Markers
    INITIAL ENCOUNTERS:

    EMERGENT CASES
    • Triaging – Initial Database
    • Non-Admissions – ER Database?
    • Admissions – Admitting Section

    OUT-PATIENT CASES
    • Minor Surgical
    1 2 3
    • Chemotherapy
    • Hemodialysis
    • Diagnostic/Therapeutic
    • endoscopy, bronchoscopy, colonoscopy,
    cystoscopy, etc.
    Identifying Key Markers
    NURSE-IN-CHARGE
    • Gives forms, sets May Go
    Home Status
    MALASAKIT
    • checking of requirements,
    Database Updated? 1 2 3
    BILLING
    • posting of Accounts Receivable
    • Transmittal
    • TAT is from Discharge to Filing
    Identifying Key Markers
    ACCOUNTING
    • Gets monthly report of
    Accounts Receivable
    (BizBox)
    • Reconciles with Claim
    Status in PhilHealth
    1 2 3
    Portal
    • If PAID, double-checks
    with CASHIER
    Identifying Key Markers
    CASHIER
    • Retrieves Auto Credit
    Payment Notice
    (ACPN) from
    PhilHealth Portal 1 2 3
    • Distributes credit into
    TFDM and TFRI
    Identifying Key Markers
    PHILHEALTH
    E-Ticket#
    • Generated by bundle after
    transmittal
    ClaimSeries#
    • Used by PhilHealth to track
    claims
    1 2 3
    • Generated by PhilHealth
    PhilHealth Portal
    • Dashboard; Doesn’t sort by
    Discharge Date
    Key Insights
    TURNAROUND TIME:
    4.3

    Billing
    • Discharge to Transmittal
    2.4
    Accounting
    2 • Discharge to Paid
    PhilHealth
    • Time Received to Paid

    Subject 1 Subject 2 Subject 3


    Key Insights
    PhilHealth Portal
    4.3
    • Does not sort by Discharge Date

    Billing and Accounting


    2.4
    • Output and Database dependent on
    2
    Discharge Date

    BizBox
    • Sometimes ClaimSeries# does not
    Subject 1 Subject 2 Subject 3 appear on the record
    Proposals

    Work with
    BIZBOX and
    Integrate
    Create Final IHOMP for
    MONITORING
    Flowchart Access to
    System
    DATA,
    DASHBOARD
    Proposals

    Lobby
    Access to Report
    PhilHealth to
    Manager, ACPN, Standardize TAT
    make Portal
    PhilHealth Internally
    Searchable by
    Portal
    Discharge Date
    Works Cited
    Thanks, Ma’am Angie! <3

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