YAKAP Capitation Payments Explained: How Clinics Get Paid by PhilHealth

So you're looking at YAKAP and the first question is: how does the money actually work?

Fair question. The payment model is different from what most clinics are used to. It's not fee-for-service. There's no billing per visit. Instead, PhilHealth pays your clinic based on how many patients are enrolled with you. That's it.

Here's exactly how it works.

Capitation: Getting Paid Per Patient, Not Per Visit

YAKAP runs on a capitation model. PhilHealth pays your clinic a set capitation rate per empaneled patient per year. Check the latest PhilHealth advisory for current rates, since these can and do change.

The important part: your payment is tied to how many patients chose your clinic as their YAKAP provider. Not how many times each patient walks through your door.

A patient who visits once a year and a patient who visits ten times generate the same capitation payment. The incentive is to attract and retain patients, not to maximize individual visits.

More empaneled patients = more revenue. Simple math.

The Two-Tranche Payment Structure

PhilHealth doesn't pay the full capitation amount in one shot. It comes in two tranches, and each one has specific requirements.

Notice how the bigger payment (60%) comes second, and it requires more complete data. This is by design. PhilHealth wants proof that patients actually received comprehensive care, not just an initial checkup.

First Tranche (40%)

Released around mid-year. To qualify, your empaneled patients need to have completed their First Patient Encounter (FPE), which is the initial in-person assessment at your clinic.

Think of the FPE as the baseline. The patient shows up, you do the initial workup, and that encounter is encoded and submitted to PhilHealth. That triggers the first tranche for that patient.

Second Tranche (60%)

Released at year-end. This is where it gets stricter. For each patient to count toward your second tranche, you need to have submitted complete encounter data: FPE, consultations, lab results, and prescriptions.

If you only did the FPE but never submitted lab results or prescriptions for that patient? You only get the first tranche. The second tranche requires the full picture.

This is the part that trips up a lot of clinics.

What Counts for Payment: Year 1 vs. Year 2+

The requirements change after a patient's first year with your clinic.

Year 1: FPE is required. This is the patient's first-ever encounter at your YAKAP clinic. No FPE, no payment.

Year 2 and beyond: FPE is no longer required. The patient just needs at least 1 consultation per year to count toward your capitation. They're already in the system; you just need to show ongoing care.

One more thing to understand: the billing basis is unique patients who actually received care. Not the total number of patients on your master list. If you have 5,000 patients on your master list but only 3,000 had any encounters, you get paid based on the 3,000.

Common Payment Issues

Let's talk about the pain points clinics actually experience.

Payment delays. They happen. Some clinics report waiting months past the expected payment date. This is a known issue across the YAKAP system. Plan your cash flow accordingly and don't count on payments arriving exactly on schedule.

Strict submission deadlines. The second tranche for the previous year typically has a March 31 deadline. Miss it and you lose that payment. There's no grace period.

Encoding backlogs. This is the silent revenue killer. If your clinic fell behind on encoding consultations, lab results, or prescriptions, those patients won't have complete records. Incomplete records mean you only qualify for the first tranche (40%), not the full capitation.

Every day you delay encoding is money left on the table.

Co-Pay: Additional Revenue from Private Clinics

Private clinics can charge patients a co-pay on top of what PhilHealth covers. There's a cap on how much you can charge, so check PhilHealth's current guidelines for the exact limit.

This means your total revenue per YAKAP patient is the capitation payment from PhilHealth plus whatever co-pay you collect from the patient. For clinics in areas where patients can afford it, this adds a meaningful revenue layer.

Not all clinics charge co-pay. Some serve communities where patients simply can't afford any out-of-pocket cost. That's a decision each clinic makes based on their patient population.

Why Your EMR Choice Matters for Getting Paid

Here's where the dots connect.

Getting paid under YAKAP comes down to one thing: submitting complete, accurate data to PhilHealth on time. FPE, consultations, lab results, prescriptions. All of it. For every patient.

If your encoding system makes this hard, you lose money. If it makes it easy, you capture your full capitation.

An EMR that handles all four data types (FPE, consultations, labs, prescriptions) in a single workflow means fewer gaps in your submissions. Automated master list import means you always know exactly who's empaneled at your clinic. Direct PhilHealth submission reduces encoding errors and avoids the delays that come with manual uploads.

The clinics that get their full YAKAP payment are the ones with clean, complete data. Your EMR is what makes that possible.