Examining PhilHealth reasons for return to hospital claims in FEU-NRMF Medical Center / Ma. Lourdes S. Erum, Monique Denise A. Evaristo, Ymmandah P. Gaffud, Marc Wilhelm M. Garcia, Patricia D. Gomez, Karen H. Gumabon, Flory-an Christy E. Ilao, Joan Pauline R. Jornacion, Adelfa Mae O. Lamsen, Aryze Thomas F. Layog, Danika Toni B. Ligores, Edmarts B. Magbitang, Pollyanna Coleen R. Marcelo, Nicole Ann M. Mateo, Vecher Denise C. Miguel, Diana Rachelle s. Navarro and Patricia Ann F. Pangilinan.

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Language: english Publication details: Fairview, Quezon City: Department of Community and Family Medicine, FEU-NRMF, 2022.Description: 75 pages: illustrations, tables; 28 cmContent type:

text

Media type:

unmediated

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volume

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LOC classification:

M CFM 2022 0031

Summary: Abstract: The increasing number of Return to Hospital (RTH) claims poses a big problem in health institutions accredited by Philippine Health Insurance (PhilHealth) due to financial loss. Far Eastern University - Nicanor Reyes Medical Foundation (FEU-NRMF) Medical Center is now facing a huge loss for funds and this compromises the quality and delivery of health care services to the patients. The present study was undertaken to determine the reasons for PhilHealth RTH claims in FEU-NRMF Medical Hospital. Descriptive study was used for all documents obtained from September 2021 with a RTH Claim from PhilHealth. The data was composed of reasons for return, the department handled the case, and the expertise of the attending physician of the RTH claims. Among the eight (8) clinical departments, the most number of RTH claims includes the Department of Internal medicine (57.21%), followed by Department of Surgery (17.07%), Department of Ophthalmology (9.62%), Department of Child Health (6.37%), Department of Obstetrics and Gynecology (5.41%), Department of Otorhinolaryngology - Head and Neck Surgery (2.40%), Department of Emergency Medicine (1.32%), and Department of Family Medicine (0.60%). A total of twenty six (26) reasons contributed for RTH claims among the different clinical departments. The top five (5) most reasons include no electronic Claim Form 4 (CF4) data attached to claim, required medical documents, errors encountered in CF4 Extensive Mark-up Language (XML) for referral to the service provider to fix and re-file, required claim forms, and discrepancies, respectively. Thus, the present study concludes that requirements provided by PhilHealth are not met by some of the departments, resulting in RTH Claims.

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Includes appendices and bibliographical references.

Abstract: The increasing number of Return to Hospital (RTH) claims poses a big problem in health institutions accredited by Philippine Health Insurance (PhilHealth) due to financial loss. Far Eastern University - Nicanor Reyes Medical Foundation (FEU-NRMF) Medical Center is now facing a huge loss for funds and this compromises the quality and delivery of health care services to the patients. The present study was undertaken to determine the reasons for PhilHealth RTH claims in FEU-NRMF Medical Hospital. Descriptive study was used for all documents obtained from September 2021 with a RTH Claim from PhilHealth. The data was composed of reasons for return, the department handled the case, and the expertise of the attending physician of the RTH claims. Among the eight (8) clinical departments, the most number of RTH claims includes the Department of Internal medicine (57.21%), followed by Department of Surgery (17.07%), Department of Ophthalmology (9.62%), Department of Child Health (6.37%), Department of Obstetrics and Gynecology (5.41%), Department of Otorhinolaryngology - Head and Neck Surgery (2.40%), Department of Emergency Medicine (1.32%), and Department of Family Medicine (0.60%). A total of twenty six (26) reasons contributed for RTH claims among the different clinical departments. The top five (5) most reasons include no electronic Claim Form 4 (CF4) data attached to claim, required medical documents, errors encountered in CF4 Extensive Mark-up Language (XML) for referral to the service provider to fix and re-file, required claim forms, and discrepancies, respectively. Thus, the present study concludes that requirements provided by PhilHealth are not met by some of the departments, resulting in RTH Claims.

Thesis - Department of Community & Family Medicine

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