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Philippines Launches First Electronic Claims System

Medilink recently launched its computerized claims clearing house network system for hospitals, HMOs, health insurers, self-insured corporations, clinics, and independent physicians associations. It is the first to provide electronic eligibility, electronic claims processing, and electronic funds transfer in the Philippines.

Presently, clients submit piles of paper to their HMOs or insurance companies if they want to to claim their benefits or services.

With Medilink, each member of a health plan will be issued a Medilink smart card. Each time a member visits an affiliated hospital or clinic, the card will be swiped through a terminal connected to the central computer of Medilink for verification of membership and health plan benefits. A print out of the benefits of the member will be issued from the terminals printer.

Upon discharge from a hospital, the health card will again be swiped and the charges entered on the terminal. A printout of the accepted charges will be printed in the terminals printer. All before the patient effectively checks out.

If the claim is within the plans specifications, it is cleared for payment. Upon instructions from the customer, Medilink electronically finalizes electronic bank transfer from the payer's account to the provider's bank account.

The growing concern for quality and and efficient healthcare services mainly among corporate employees has resulted in the proliferation of HMOs in the country.

After an aggressive, rate-cutting expansion phase, several HMO's owned and operated by doctors are now facing a phase of consolidation because of natural inefficiencies and human limitations in their administrative systems, according to market sources.

Around 2 to 2.5 million Filipinos are presently covered by HMOs and Non-Life Insurance companies with health plans. The country at the moment has around 40 HMOs. This number is expected to double in a couple of years. The business volume of the HMO sector reaches 2 billion pesos per annum.

While the hospital sector is highly interested in prompt payments, the HMO sector is seriously challenged to improve eligibility and claims efficiency, according to a survey conducted by Medilink.

"We can guarantee that the system we built is very reliable," said Deither Bruckner, general manager of AIZ Information Services. "We're using the Equitable Card Network infrastructure to facilitate the electronic transfer of electronic documents to electronic payment in this system."

Medilink implemented the first of its three business phases; an eligibility phase started in March 1999 where they have signed up several major HMOs which will process part or all of their members at selected hospital coordinators in Metro Manila.

The first phase in Manila will be finalized by May 1999 and its Roll out to key provincial areas will follow.

The eligibility phase is the groundwork for the claims processing. Data downloaded on to the Medilink server from the Managed Care companies is required for the future claims processing services.

The second and third phases implementing the Electronic claims processing and electronic fund transfer are scheduled for May/June 1999.

A Medilink service providing emergency data will be available second half of 1999. The structure of this data complies with the G7 and the European community agreement.

The Emergency Data Service will, according to sources, be designed to process medical information quickly during emergency cases when a patient is unconscious.

"We're still finalizing the details of this service and how we'll be introducing this to the market," said Bruckner.

Managed care organizations, insurance companies with Health plans, IPAs and self-insured corporations may subscribe to Medilink electronic claims clearinghouse services as payer subscribers. Hospitals, clinics, independent physicians may join the Medilink service as service provider subscriber.

Medilink expects to process around 80% of the submitted in-patient claims by the service providers to be processed electronically without human intervention of any kind. The rest of the in-patient claims will still need human intervention for authorization and payment.

At this moment, eligibility of members for medical services from several HMOs namely, MaxiCare and MediCard, are verified utilizing Medilink terminals fielded at Makati Medical Center, St. Luke's Medical Center in Quezon City, Medical City General Hospital and Health Solutions in Mandaluyong City.

"Also, we're going to provide outpatient claim services as well," said Bruckner."We are now training MaxiCare Hospital Liason Officers in Quezon City on how to use the Medilink system. This will be rolled out next week initially with hospitals like St. Luke Medical Center, Polymedic Hospital , Metropolitan Hospital, and Manila Doctors Hospital.

Medilink, is a cooperative effort between AIZ, a company of the Zuellig Group, and the Equitable Card Network. The joint venture was supported by SGV Arthur Andersen as its system integrator.