PhilHealth

My source for this week’s column is someone who has been dealing with PhilHealth, but does not want to be identified: “To me the fact that Mr. Dante Gierran is a lawyer and CPA gives some confidence that he can do the job. PhilHealth’s problem is governance, unless this is resolved at root, simply changing the leadership would be akin to rotating the cast of an otherwise recurring drama. They need to retool their processes. Perhaps a coalition of respected audit firms could design the processes and financial controls. The operations aren’t that complex, but involve large volumes of transactions.”

I presume Mr. Gierran would choose tested and credible investigators from the government. But the PhilHealth scandal has hit such a high pitch, it would be best if he hired the suggested consortium of auditors from the private sector.

I quote directly from this individual who understands the challenges of PhilHealth:

1. Governance policies and financial controls

• PHIC is the national insurer. Ideally, it would also be regulated by the Insurance Commission.

• Appoint consortium of professional audit firms to design governance policies and financial controls that are aligned with global best practices

2. Processes

Procurement:

For any large-ticket items, bidding process must be fully transparent to the public. Ideally, it would be conducted online, with electronic logs and audit trail.

i. Public Request For Proposal (RFP). Detailed description of requirements, including manufacturer, model, supplier, unit price, target delivery date.

ii. Bids that are submitted by each supplier would be assessed against comparables. If these are commodity items, assuming PhilHealth purchases multiple units, its bid price should be more favorable than retail price.

iii. Digital signatures on approval documents. Digital signature platforms log the date and time of signature to enforce accountability and avoid back-dating.

iv. Payment records should be publicly disclosed.

Underwriting:

i. Initiate a member verification campaign. With mobile apps, it is possible to conduct remote Know Your Customer (KYC). Members could be required to upload a government ID, take a selfie, then register a mobile number and email address. A successfully verified member should then be able to download an electronic PhilHealth ID to supplement or replace an existing plastic PhilHealth ID. Besides being a convenience feature that is relevant during this pandemic, this process would help prevent enrollment of new fictitious members and weed out extraneous records.

ii. There should be regular reconciliation of paid premiums versus number of cards disbursed.

Customer care hotline:

i. All queries should be ticketed, and service levels for resolution tracked and reported. There is no such ticketing system today. The hotline number is rarely answered since many staffers are working from home.

ii. Consider outsourcing customer care to third party specialists, such as any of the large BPOs who can craft solutions that combine chatbots for recurring simple queries and live support for more complex issues.

Claims processing:

i. Publish clear validation rules, test cases, and certification renewal process for solution providers to implement PhilHealth circulars. Currently, solution providers are left to self-interpret and self-regulate compliance to PhilHealth circulars.

ii. Standardize processes across all regions. Presently, each region has its own interpretation of requirements, using the many free-form text boxes to implement their specific regional requirements.

iii. Remove all free text fields, all inputs must be coded. Publish standard procedure codes to be used by all health facilities across the country (CPT codes). Diagnosis must be coded ICD10. Coded procedures and diseases combinations should be cross-referenced for relevance using Artificial Intelligence.

iv. Eliminate all manner of “manual” claim adjudication. Automate adjudication using both business rules and Artificial Intelligence. Outliers should be investigated by a third party as part of a normal incident monitoring and management process.

3. People

i. Leadership team should be held to a higher standard befitting a public servant. Minimally, candidates or incumbents should pass regular background checks for credit, legal, lifestyle that is standard in the private sector.

ii. Annual personal attestations (e.g., this is a convention at professional associations such as the CFA Institute).

It is my hope that regional changes will be properly vetted and devoid of political pressures.

This is respectfully submitted to Mr. Gierran for serious consideration.