The friction between clinics and payers is quietly draining billions from Southeast Asia’s health system. It won’t be closed by goodwill — it needs a dedicated layer in the middle, and we should be honest about why.
A few months ago, I watched a diagnostic clinic sit on a stack of 174 unpaid claims. The care was correct. The patients were covered. The claims were stuck anyway — because the paperwork between that clinic and its eight different payers had its own private grammar. Different forms, different portals, different evidence requirements, different payment cycles. The doctors were excellent. The receivables were frozen.
That scene stayed with me because of what it revealed. The clinic wasn’t failing at medicine. The insurers weren’t failing at coverage. Everyone was doing their actual job well. The money was simply trapped in the space between them — a space that, structurally, nobody owns. And what nobody owns, nobody fixes.
That missing middle is the most expensive empty seat in our health system.
The scale of the leak
Start with the numbers, because this is an accounting problem before it is anything else.
PhilHealth itself reported that ₱4.49 billion in return-to-hospital claims from 2024 were never refiled — more than 316,000 individual claims that facilities were unable to return to the system before the window closed. The overwhelming majority were not fraudulent. They were denied on administrative grounds — a missing signature, a documentation mismatch, a deadline — and then abandoned, because chasing them costs time and people that a clinic on thin margins doesn’t have. The state insurer has openly acknowledged that hospitals have closed under the weight of delayed and denied reimbursements.
Multiply that logic across the private side: every clinic reconciling with multiple HMOs, each payer its own maze, every denial a small judgment about whether the appeal is worth the labour. Often it isn’t, so the money is written off. Quietly, constantly, at scale.
This isn’t a Philippine quirk. Across Southeast Asia, out-of-pocket health spending still runs as high as 50% in some markets, and private providers carry the bulk of outpatient care. And one detail in the research deserves attention: among the oldest reasons insurers historically avoided financing that fragmented primary-care layer was the pervasiveness of fraud and fragmentation in medical claims — a problem that persists today. The capital is willing. The coverage exists. What’s been missing is a trustworthy, intelligent middle that makes the flow between them safe to fund.
We spent a decade building the front end of universal health care — enrolment, benefits, coverage. We barely built the back office that makes it actually pay.
Why goodwill won’t close it
The instinct is to treat this as a shared duty, solved by cooperation and good intentions. I used to think that too. I don’t anymore.
The middle stays empty precisely because it is no one’s core business. A clinic’s job is to deliver care; reconciliation is overhead it tolerates. An HMO’s job is to price and manage risk; chasing a provider’s documentation gaps is not where it wants its people. A financier’s job is to deploy capital; it can’t price receivables it cannot clearly see. Each party is rationally protecting the integrity of its own operation — and that integrity is exactly why none of them will adopt the messy, cross-cutting work of the middle as their own.
So the gap doesn’t close because everyone agrees to care more. It closes when the connective work becomes someone’s actual responsibility, resourced and accountable, rather than everyone’s afterthought. This is not a new pattern. The most durable infrastructure in finance — the layers that clear payments, reconcile ledgers, service loans — exists because a specialised party took ownership of the connective tissue the principals didn’t want to handle. Those layers never touch the underlying capital or the underlying service. They make the system flow. Healthcare finance in this region has no such layer. It needs one.
What the layer does — and what it doesn’t touch
Worth being precise, because anyone wary of another player crowding their territory deserves a clear answer.
A middle layer like this does not deliver care. It does not underwrite risk. It does not hold anyone’s funds. It does not compete with a clinic, an HMO, or a financier on their home ground. It does the one thing the middle has always lacked: it turns the chaos between parties into clean, shared, decision-grade data.
In practice, that looks like:
- Reconciliation handled on the provider’s behalf, so receivables move in days rather than months, without each clinic building an in-house back office.
- A common language between payers and providers — translating each insurer’s private grammar into one consistent standard, so denials fall at the source instead of being re-learned clinic by clinic, forever.
- Cross-network analytics no single stakeholder can produce alone — because the layer sees across many providers and many payers at once, it can surface patterns invisible from inside any one organisation: which denials are systematic, where capital is being trapped, what a payer’s behaviour actually predicts.
- A financeable view of receivables — once the middle is transparent and trustworthy, capital can flow to providers who today wait months to be paid. The receivables market everyone has avoided becomes one that can finally be priced.
None of that interferes with anyone’s existing role. It fills the gap that serves all of them.
Why Southeast Asia should build this — and own it
There’s a leapfrog opening here worth naming. The region has a habit of waiting for a mature playbook from elsewhere, then localising it years too late. We did the opposite with payments — skipped the credit-card era, went straight to mobile wallets, and now other parts of the world study us.
Healthcare finance is a similar opening. Our systems are fragmented enough that there’s no entrenched legacy to defend, and the technology is finally good enough to build the intelligence middle natively rather than bolting it onto decades-old infrastructure. We don’t need to import a foreign model. We can design the one that fits an emerging-market reality — high out-of-pocket spending, many small providers, multiple payers, thin administrative capacity — and become the region that exports it.
But that requires the people who have to be in the room to actually be in the room.
The conversation worth having
Here’s the part most of us hedge on, so I’ll say it plainly: a great deal of this ecosystem is quietly losing money to a problem we’ve all agreed to treat as the cost of doing business. It isn’t. It’s an unowned middle — and unowned middles get owned eventually, by someone. The open question is whether ours gets shaped here, by the stakeholders who live with it, or is inherited later from a design made elsewhere.
That is a discussion the people closest to the pain should be having directly with each other — clinics drowning in denials, HMOs frustrated by poor claims data, financiers who can’t see the receivables, regulators holding the system’s integrity, and the founders building into the gap. They rarely sit at the same table. They should.
I don’t think the answer gets handed down. I think it gets argued out by the people it costs the most. If you’re one of them, this is the conversation to be early to.
Alel Flor Auxillos-Cayanan is co-founder and CEO of MediPaid, a Philippine healthtech company working on claims and receivables infrastructure for clinics and HMOs, and is convening the Healthcare Finance Intelligence Council (HFIC), a stakeholder round table on the issues raised here. She can be reached for that conversation.
