ABSTRACT
The Philippine Universal Health Care Act mandates PhilHealth as a strategic purchaser, yet claims inefficiencies strain public hospitals. This study examined Western Visayas Medical Center’s (WVMC) Medical Claims Clearinghouse (MCCH), which internalized traditionally outsourced validation functions. Using thematic analysis of interviews and records, the study found the MCCH successfully mitigated liquidity risks. By reallocating personnel and utilizing free digital tools, the unit achieved 941 consecutive claims with zero returns-to-hospital through pre-discharge reviews. Key outcomes included a 67.54% reduction in coding errors and improved turnaround times. Despite challenges, best practices—including clinical-financial feedback loops and real-time dashboards—demonstrate that adaptive innovation strengthens revenue cycle management, offering a replicable framework for resource-constrained hospitals under Universal Health Care. Thus, strategic institutional shifts can transform administrative hurdles into sustainable financial stability.
Keywords: Medical Claims Clearinghouse, revenue cycle management, claims processing, Universal Health Care, public hospital, Philippines
INTRODUCTION
The Universal Health Care Act positions the Philippine Health Insurance Corporation as the national strategic purchaser of health services. However, operationalizing this mandate has been hampered by structural bottlenecks, including weak purchasing leverage, delayed provider reimbursements, and fragmented financing mechanisms across local government units (Co et al., 2024; Uy, 2024). As the primary payer, PhilHealth’s centralized claims processing has created a “single point of failure” within hospital revenue cycles, with state auditors flagging massive backlogs of unpaid claims and data integrity issues (Commission on Audit [COA], 2023). These delays are often worsened by rigid adjudication policies and frequent shifts in payment mechanisms, which have increased denial rates and Return to Hospital (RTH) claims (Medina et al., 2024). For government hospitals, these disruptions threaten operational liquidity; as of late 2024, government hospitals reported approximately PHP 14.8 billion in unpaid PhilHealth claims, while RTH claims—returned solely for clerical correction—were estimated at PHP 4.5 billion (The GUIDON, 2025; Philippine Daily Inquirer, 2025). In response, the Western Visayas Medical Center (WVMC) in Iloilo City initiated a strategic shift: the establishment of an In House Medical Claims Clearinghouse (MCCH). This study examines the challenges encountered and best practices developed in the conceptualization, implementation, and outcomes of this pioneering model, with the goal of providing a replicable framework for other public hospitals.
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