The Member Journey is the Product: Lessons for Philippine HMOs in the PhilHealth Era

On 1 October 2026, PhilHealth, the country's national health insurer, and 13 HMOs and private insurers signed an agreement to share the cost of care. ^[1][2] PhilHealth, through its YAKAP programme, covers the first layer of primary care: consultations, 13 laboratory tests, selected outpatient medicines and cancer screening. HMOs cover what lies beyond it, such as specialized procedures, branded medicines and room upgrades. PhilHealth's acting president put the aim simply: more care for every peso. ^[2]

Recent industry figures point the same way. In the first half of 2026, HMO membership fees grew about 20% to ₱54.8 billion ^[3], while healthcare benefits and claims paid grew 13.6% to ₱41.2 billion ^{[4]. The Insurance Commission attributes the higher payouts to increased use of healthcare services.}

More members, more use and now a second payer in the picture all mean one thing for HMO leaders: there are more moments in a member's journey where service can go wrong. Those moments are where loyalty is won or lost.

Three places where HMO service breaks

Most member complaints trace back to one of three points in the journey. Each one also hurts a different person: the member, the doctor or clinic, and the HMO's own team.

1. The question nobody can answer quickly. A member asks whether a test is covered, what their limit is, or which clinic is accredited. If the answer takes three calls and a callback, they have already formed an opinion. Questions about pre-existing conditions and coverage limits are the ones members remember, because the answer decides what they pay.

2. The approval that takes too long. The letter of authorization (LOA) is the member's permission slip for care. When it is delayed, the member waits at the clinic or hospital, the doctor's staff chase the HMO, and the member calls again for an update. One slow LOA creates several contacts, and some of them become formal complaints.

3. The claim that disappears into the back office. Claims arrive as documents, scans and emails. Checking them, calculating the reimbursement and releasing payment is slow when each step depends on someone re-keying information. For doctors the stakes are real: clinics carry rent and salaries whether or not reimbursements arrive, and healthcare groups have warned that prolonged payment delays can lead providers to drop an HMO's accreditation.

These three problems are connected. A confused member calls about a delayed LOA, which was delayed because documents were incomplete, which is also why the doctor's claim is stuck. Treating them as separate departments' issues is why they stay unsolved.

The new PhilHealth coordination adds a fourth pressure. When a member is covered by both PhilHealth and an HMO, someone has to explain which one pays for what, and the HMO's service team is usually the first to be asked.

One journey, three capabilities

The member journey runs left to right. Customer support runs across the whole journey, LOA issuance sits at the approval step, and claims adjudication handles everything after care is received.

The practical fix is to run these as one connected operation rather than three queues. When support can see the status of an LOA, the member gets an answer on the first call. When the LOA team knows what documents a claim will need, fewer claims stall later. And when the back office closes the loop on payment, the doctor's clinic stops chasing.

How TP supports Philippine HMOs

TP runs these workflows for HMOs in the Philippines, from first inquiry to final claim. That includes round-the-clock voice, chat and digital support for members and providers, LOA processing and medical administration, and back-office claims work such as document intake, data verification, reimbursement calculation and regulatory reporting aligned with Insurance Commission standards. The aim is for support, approvals and claims to work as one connected operation, with people supported by automation where it helps.

The strategic imperative

HMOs will keep competing on price and network, but members and doctors will judge them on something simpler: did it work when I needed it? With PhilHealth coordination arriving and use of care rising, the HMOs that connect support, approvals and claims will stand out. Which step in your own member journey would your members say lets them down most?

Connect with our experts to explore how a connected member and claims operation could work for your HMO.

Sources

1. PhilHealth, HMOs forge pact to split healthcare costs, Manila Times, 1 Oct 2026

2. PhilHealth and HMOs team up to lower health care costs, Daily Tribune, 2 Oct 2026

3. Philippine HMO market sustains nearly 20% growth, iCare, 9 Sep 2026, citing Insurance Commission H1 2026 data

4. Philippine HMOs pay out US$711m in health benefits in H1 2026, Asia Insurance Review