The Level of Effectiveness of PhilHealth Claims Processing in Sorsogon Medical Mission Group Hospital and Health Services Cooperative

Many healthcare providers in the Philippines are complaining about the delays in payment of PhilHealth of their arrears. In line with this, the researcher would like to determine if the delay starts from the provider itself. Moreover, it can be observed nowadays that healthcare services are availed by many. This suggests more transactions related to health insurance. Therefore, healthcare facilities need proper monitoring to know if claims are processed and paid for by insurance companies. This study was made to know the level of effectiveness of PhilHealth claims processing of one of the private hospitals in Sorsogon City, which is Sorsogon Medical Mission Group Hospital and Health Services Cooperative (SMMGHHSC). It is by determining the status of these claims in terms of the average number of days to collect documents, transmit the claims to the said insurance company, convert receivables into cash, reprocess the returned claims, and the status of current systems being utilized. Further, the level of effectiveness of processing these claims along with document requirements and timeliness, as well as the gaps and issues encountered in the process, were also determined. This could help other institutions to evaluate and improve their internal process. All employees of the Claims Unit of SMMGHHSC, comprising eight (8) staff from the hospital and three (3) staff from its satellites, serve as respondents. This study used a questionnaire, and interview and involved the process of observation in obtaining relevant data in attaining the desired result. The researcher also culled out actual patients’ records to support the aforementioned data-gathering procedures. Further, the triangulation method was used on patients’ records covering the year 2021 confinement, to develop a comprehensive understanding of the data.