PhilHealth OPD Claims-Leakage Calculator

Recoverable · per hospital / yr

₱3.8M

₱3,804,000 per year

Recoverable · full rollout / yr

₱60.9M

across 16 hospitals

Return on investment

10.1×

recovery ÷ annual system price

Just 1.6 hospitals' recovered claims cover the entire system. The rest is pure recovered revenue.

Your hospital

Adjust to match real figures — ask billing for last year's submitted claims value.

Annual PhilHealth claims submitted₱60,000,000

Total value of claims the hospital files with PhilHealth per year.

Annual OPD consultations60,000

~200/day × 300 days for a mid-size hospital.

Hospitals in rollout16

16 = all Cebu Capitol-run hospitals.

System price (annual)₱6,000,000

Annual license for the full deployment.

Where the money is

Two buckets — one measured in PhilHealth's own stats, one invisible to them.

A · Denied & returned claims recovered₱1,104,000

Causes are all administrative — 60-day lapses, missing docs, clerical errors — so they're preventable.

Gross denied + RTH / yr₱2,760,000

Permanently lost today₱1,380,000

Recovered by AI (80%)₱1,104,000

B · Never-filed encounters captured₱2,700,000

Services rendered but never billed — because the doctor never documented. The scribe captures them at point of care.

Gross unbilled eligible / yr₱5,400,000

Captured by AI scribe (50%)₱2,700,000

Total recoverable · per hospital / yr₱3,804,000

Assumptions & grounded rates — tap to adjust ▾

Every rate below is pre-filled from published PhilHealth 2024 figures. Change any of them to stress-test the estimate.

Denied + RTH rate (% of submitted)4.6%

₱8.9B denied+RTH ÷ ~₱193.6B submitted (2024).

% permanently lost (not refiled)50%

₱4.5B of ₱8.9B unresubmitted by year-end 2024.

AI recovery on admin leakage (A)80%

Causes are deadlines/docs/clerical — all AI-preventable.

% OPD consults that are claimable18%

Animal-bite, TB-DOTS, minor surgery, maternal/newborn, etc.

% of claimable never filed20%

Doctor didn't document → clerk couldn't bill. Invisible in stats.

Avg reimbursement / never-filed₱2,500

Blended OPD package value.

AI capture on never-filed (B)50%

Share of currently-lost encounters the scribe converts.

Konsulta capitation (₱1,700 per registered member / year) is additional upside not modeled here — treat it as a bonus.

Sources · published PhilHealth 2024 data

₱4.7B 483,000 denied claims in 2024 — mostly 60-day filing failures · Philstar 2025-01-15
₱4.2B 304,082 Return-to-Hospital claims — missing docs, clerical errors · Philstar/GMA 2025-01-22
₱4.5B RTH claims never resubmitted — permanently lost · Philstar 2025-01-22
85.4% first-pass paid rate — ~1 in 7 claims not clean first pass · PhilHealth
₱165.34B total 2024 benefits — ₱91.32B to government hospitals · PNA
₱1,700 Konsulta capitation per member / year · Philstar/PNA 2024

Estimates model administrative recovery only and do not constitute a guarantee of reimbursement. This tool never processes, submits, or inflates claims — it supports complete, correctly-coded, audit-defensible documentation. Figures scale with each facility's actual claims volume.