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Case rates presentation gen rules
 

Case rates presentation gen rules

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  • Case payment mechanism for the most common medical and surgical conditions encountered in the country Comprise up to 49% of total claims from preceding years Rates were computed based on percentage weights given to 3 cost references: (1) tariff rates of the case mix project where costs came from 18 participating govt and pvt hospitals (top-down approach); (2) contracting rates from 5 govt and pvt hospitals; and (3) PhilHealth average value per claim Adopted a “No Balance Billing Policy” (NBB) to protect the most vulnerable groups including the poorest of the poor This aim to improve turn-around time for claims processing and payment to providers in order to achieve better cost-efficiency for PhilHealth and faster reimbursements for members and accredited providers.
  • Reimbursement shall be made directly to the facility Hospitals shall act as the withholding tax agent for PF PF for case rates are inclusive of payment to all doctors who attended or managed a specific case Government hospitals shall facilitate the payment of the PF share to health personnel subject to the existing rules on pooling (Sec 35 of RA 7875 as amended and its IRR and PC No. 27 s-2009)
  • For purposes of efficient processing of claims, all accredited facilities are required to provide correct RVS and/or ICD-10 codes in Claim Form 2 Reimbursement of case rate packages shall be based on the main condition ( PC No. 04, s-2002) The total number of confinement days shall be deducted from the 45-day limit per calendar year For hemodialysis and radiotherapy, one (1) day shall be deducted from the 45-day allowance per year for each availment Existing rules on the 45-day limit will apply for outpatient packages for Malaria and HIV-AIDS TB-DOTS is excluded from the 45-day limit The case rates shall follow the rule on single period of confinement except for hemodialysis and radiotherapy packages, where availment is on a per session basis.
  • “ No Balance Billing” Policy shall mean that no other fees or expenses shall be charged or paid for by the patient-member above and beyond the packaged rates. Drugs, supplies, or diagnostic procedures that are not available, facility should purchase necessary items/services in advance on behalf of the member. Any out-of-pocket payment made by members shall automatically be deducted against claims of the hospitals with corresponding sanctions or penalties the Corporation may charge.
  • No Balance Billing (NBB) Policy shall be applied to ALL SPONSORED Program members and/or their dependents for the specified cases under the following conditions: When admitted in government facilities/hospitals. When claiming reimbursement for outpatient hemodialysis and radiotherapy performed in accredited government hospitals and non-hospital facilities (e.g. FDCs, ASCs) Facility to provide all necessary drugs, supplies (including dialyzer), doctor’s service Excludes maintenance drugs, laboratory tests
  • Exemption to the general rule limiting the NBB policy to Sponsored Program Members and in support of the country commitment to reduce maternal and infant mortality rates and improve maternal and newborn care enunciated in the Millenium Development Goals (MDG)  The NBB policy shall also apply to ALL PhilHealth members regardless of membership type in ALL accredited MCP (non-hospital) providers  This shall cover claims for MCP and Newborn Care Package (NCP) in said facilities
  • “ No Balance Billing” Policy shall mean that no other fees or expenses shall be charged or paid for by the patient-member above and beyond the packaged rates. Drugs, supplies, or diagnostic procedures that are not available, facility should purchase necessary items/services in advance on behalf of the member. Any out-of-pocket payment made by members shall automatically be deducted against claims of the hospitals with corresponding sanctions or penalties the Corporation may charge.
  • The facility shall then make the necessary adjustments and application of sanctions to the health professional/s In instances wherein the case rate was already paid in full to the facility; but the official receipts were not attached to the claim application, the member may request for re-adjustment. This shall be evaluated and paid accordingly to the member This shall be charged to future claims of the health facility with corresponding sanctions or penalties the Corporation may charge.
  • Breakdown of package Provision of essential newborn care to include the following: cord clamping, drying of the newborn, immediate skin-to-skin contact, washing, breast feeding, weighing of the newborn, eye prophylaxis, and Vitamin K administration (Php 250) Professional fee (including breastfeeding advice) (Php 500) BCG vaccination (Php 100) Hepatitis B immunization (1st dose) (Php 250) Newborn Screening Test (NBS) (Php 500) Newborn Hearing Screening Test (Php 150) TOTAL = 1,750
  • Breakdown of package Provision of essential newborn care to include the following: cord clamping, drying of the newborn, immediate skin-to-skin contact, washing, breast feeding, weighing of the newborn, eye prophylaxis, and Vitamin K administration (Php 250) Professional fee (including breastfeeding advice) (Php 500) BCG vaccination (Php 100) Hepatitis B immunization (1st dose) (Php 250) Newborn Screening Test (NBS) (Php 500) Newborn Hearing Screening Test (Php 150) TOTAL = 1,750
  • Claims shall be subject to medical and utilization review to ensure provision of adequate and quality health care services, such as under or over-utilization of services. PhilHealth shall regularly monitor compliance to the provisions stated in this Circular to ensure standardized implementation. To monitor compliance to the No Balance Billing policy, the original or certified true copies of official receipts should be submitted if additional payment has been made by the member to the facility or doctor. Accredited providers that violate any section of this Circular shall be included in the Provider Assessment Monitoring System (PAMS) and will be subjected to warranties of accreditation or any offenses against the Corporation and shall also be reported to the DOH and/or PRC for appropriate action

Case rates presentation gen rules Case rates presentation gen rules Presentation Transcript

  • Shirley B. Domingo, MD, MPH Vice President PRO NCR & Rizal
  • No. of received MONTH No. of RTH claims % of RTH        Jan-12 14,669 78,347 18.72 Feb-12 15,763 86,083 18.31 Mar-12 13,889 84,585 16.42 Apr-12 Source: Monthly operations report
  • HOSPITAL CLAIMSJOSE R. REYES MEMORIAL MEDICAL CENTER 330UNIVERSITY OF STO. TOMAS HOSPITAL 305CHINESE GENERAL HOSPITAL & MEDICAL CENTER 274UNIVERSITY OF STO. TOMAS HOSPITAL 136METROPOLITAN MEDICAL CENTER 130GAT ANDRES BONIFACIO MEMORIAL MEDICAL CENTER 129MCU-FDT MEDICAL FOUNDATION HOSPITAL 86CARDINAL SANTOS MEDICAL CENTER 80PERPETUAL HELP HOSPITAL 78F.Y. MANALO MEDICAL FOUNDATION - NEW ERA GENERAL HOSPITAL 76
  • MAKATI MEDICAL CENTER 489UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER, INC. 322FORT BONIFACIO GENERAL HOSPITAL 257UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER, INC. 221TAGUIG-PATEROS DISTRICT HOSPITAL 122MPI-MEDICAL CENTER MUNTINLUPA 121RIZAL MEDICAL CENTER 118ST. LUKES MEDICAL CENTER - GLOBAL CITY 110THE MEDICAL CITY 104MPI-MEDICAL CENTER MUNTINLUPA 103
  • K Original Philhealth Claim Form 2 not properly accomplishedl Required medical documents Required claim form (s)o Other documents requiredr No proof of contribution.r Original Philhealth Claim Form 3 not properly accomplishedl No proof of Professional fee billing/paymente Discrepanciese No proof of hospital billing/paymenti No proof of dependency
  • 1. Filed beyond 60 days2. Exhausted 45 compensable days3. Case not compensable4. Benefit exhausted5. Denied due to non-compliance6. Inconsistent data7. Patient not a qualified dependent8. Confinement not within the hospital accreditation period9. Less than 24 hours confinement, case not emergency10. Lack of/no qualifying contribution
  • PhilHealth does not pay for all your health carecosts.PhilHealthpays only for covered items andservices when requirements are metMembers are balance billed for the portion ofthe actual cost that is not covered by PhilHealth
  • Claims Filing
  • ENHANCED CLAIMS FORMSCircular 12, s-2010
  • CF1 (PART I)
  • 2 0 1 2 3 4 5 6 7 8 9 1 331-1234 ABC MANUFACTURING COMPANY UNIT 1 ABC BLDG., 456 MAPAGMAHAL ST., BGY. MABILIS QUEZON CITY 1100MARIO A. CRUZ MANAGER 09 04 2010The employer or his/her authorized representative shall affix his/her signature certifying that all monthly premium contributions for and in behalf of the member, while employed in their company, including the applicable three (3) monthly premium contributions have been deducted/ collected and remitted to PhilHealth during the past six (6) month period prior to the first day of confinement and the information supplied by the member or his/her representative are consistent with their available records
  • CLAIM FORM 2Beginning September 01, 2010
  • PART I – HEALTH CARE PROVIDER INFORMATION
  • 5,000.00 5,000.00For benefit packages not requiring itemization PHIC benefit should be indicated in 11e
  • DR. PEDRO A. GOMEZ 09/05/101 502 1 2 3 4 5 6 1
  • PART I – PATIENT’S CLINICAL RECORDThis claim form will support the information supplied in the Claim Form 2 and shall be used in the evaluation of proper case type determination especially TYPE D CASES, EMERGENCY CASES and LESS THAN 24 HOURS ADMISSIONSThis is mandatory in: Level 1 Facilities; Case type D; Maternity Care Package; Emergency / Transferred cases; and Less than 24 hours confinement
  • PART II – MATERNITY CAREPACKAGECF3 shall be accomplished forMCP claims (lying-in clinics) andmust be submitted together withCF1 and CF2
  • ELIGIBILITYREQUIREMENTS
  • 9 months premium within12 months priorto admission (onselected surgical cases) Eligibility Requirements
  • Qualifying Contributions / EligibilityRequirements: Employed / KASAPI 3 months within the immediate 6 months prior to availment Properlyaccomplished PartII of CLAIM FORM 1
  • Qualifying Contributions / EligibilityRequirements: IPP and Organized Grp* At least 9 within the immediate 12 months of contribution = Official Receipt / MI-5 or proof of payment for MCP At least 3 within the immediate 6 months (for NCP)
  • illustration of IPMs qualifying contribution At least 9 months of premium contribution within the immediate 12 months prior to availment (MCP)4TH QTR 1ST QTR 2ND QTR 3RD QTR OCT NOV DECO N D J F M A M J J A S AVAILC O E A E A P A U U U E MENT AVAILMENTT V C N B R R Y N L G P 12 11 10 9 8 7 6 5 4 3 2 1 12 11 10 9 8 7 6 5 4 3 2 1
  • Qualifying Contributions / EligibilityRequirements: OFW MDR (eligibility / coverage is reflected)
  • Qualifying Contributions / EligibilityRequirements: Sponsored PhilHealth Sponsored ID 19-123456789-1 (eligibility / JUAN A. DELA CRUZ coverage is reflected) OCT 13, 2010 – OCT 12, 2011
  • Qualifying Contributions / EligibilityRequirements: NPM PhilHealth Non- Paying ID or Lifetime Member ID
  • Guide to Reimbursement
  • Single Period of ConfinementRe-admissions due to same illness within a 90-day period shall only be compensated within one (1) maximum benefit: Availment for the same illness or condition which is not separated from each other by more than 90 days will not be provided with a new benefit  Only the remaining benefit from the previous confinements may be availed
  • Single Period of ConfinementBenefit for Drugs Tertiary Hospital Remaining Systemic Viral Infection Benefit Ordinary 4,200 Admission 2,000 2,200 January 15 Admission  2,000 200 February 15 Admission 1800  March 15
  • Case Types Surgica Medical lA 80 and Simple belowB Moderate 81- 200C Severe 201- 500D Extremel 501 and y severe above
  • Case-type A B C D Level 3 & 4 Hospitals (Tertiary)Room & Board* P500/day P500/day P800/day P1,100/dayDrugs and Medicines** P4,200 P14,000 P28,000 P40,000X-ray, Lab & Others P3,200 P10,500 P21,000 P30,000 Level 2 Hospital (Secondary)Room & Board* P400/day P400/day P600/day N/ADrugs and Medicines** P3,360 P11,200 P22,400 N/AX-ray, Lab & Others P2,240 P7,350 P14,000 N/A Level 1 Hospital (Primary)Room & Board* P300/day P300/day N/A N/ADrugs and Medicines** P2,700 P9,000 N/A N/AX-ray, Lab & Others P1,600 P5,000 N/A N/A
  • Case type A: Acid peptic disease Benefit Item Makati Fort Bonifacio Taguig medical General DoctorsRoom/Board Center P500/day Hospital P400/day Hospital P300/dayDrugs P4,200 P3,360 P2,700Lab/Supplies P3,200 P2,240 P1,600 Benefit Item Makati Fort Bonifacio Taguig medical General Doctors Center Hospital HospitalRoom/Board P500/day P400/day xDrugs P14,000 P11,200 xLab/Supplies P10,500 P7,350 x
  • Benefits per Single Period of Confinement Primary Secondary Tertiary 2,700 – 9,000 3,360 – 22,400 4,200 – 40,000Benefit depends on: Hospital category Case type of illness (A, B, C or D) Covered by rule on single period of confinement Benefit also depend on other claims processing guidelines:  Compliance to PNDF, generics law and Rational drug use– must be in accordance to dosage, preparation and use specified in PNDF  Only drugs used during confinement are paid (with exception)  Drugs bought by members may be reimbursed
  • Drugs and Medicines All drugs, supplies, and lab used on the day of the operations shall be paid  Must be supported by official receipts Official receipts dated 30 days prior to claimed session is allowed
  • Drugs and MedicinesDrugs must be written in generic namePNDF is main reference for paymentTo be disallowed payment: No generic name indicated* Non-PNDF drugs *except patients’ claims for medicines bought outside the hospital
  • Supplies, X-ray, Lab & Ancillary Benefits per Single Period of Confinement Primary Secondary Tertiary1,600 – 5,000 2,240 – 14,700 3,200 – 30,000 Benefit depends on: Hospital category Case type of illness (A, B, C or D)  Covered by rule on single period of confinement  Benefit also depend on:  Medical necessity  supplies, x-ray, laboratory and ancillary procedures used during confinement are paid
  • Benefits per Use of Operating Room Primary Hospital 500 pesos Secondary HospitalRVU 30 and below 750 pesos RVU 31 - 80 1,200 pesos RVU 81 – 600 (RVU x 15 PCF) Minimum: 2,200 pesos Maximum: 7,500 pesos RVU 81 – 146 2,200 pesos RVU 147 – 500 2,205 – 7,500 pesos RVU 501 - 600 7,500 pesos
  • Benefits per Use of Operating Room Tertiary HospitalRVU 30 and below 1,200 pesos RVU 31 - 80 1,500 pesos RVU 81 – 600 (RVU x 20 PCF) Minimum: 3,500 pesos RVU 81 – 175 3,500 pesos RVU 176 – 600 3,520 – 12,000 pesos
  • Professional Fee
  • Daily Visit Primary Hospital A BGP per day 300 400 Maximum per 1,200 2,400 confinementSP 500 600 Maximum per 2,000 3,600 confinement Secondary Hospital A B CGP per day 300 400 500 Maximum per confinement 1,200 2,400 4,000SP 500 600 700 Maximum per confinement 2,000 3,600 5,600
  • Tertiary Hospital A B C DGP per day 300 400 500 600 Maximum per confinement 1,200 2,400 4,000 6,000SP 800 Maximum per confinement 8,000 Maximum A B C D days perconfinemen 4 days 6 days 8 days 10 days t
  •  Surgeons’ fee depends on:  RVU of the procedure  PCF depending doctor category (3 tier) GP (40 pesos) Doctor with training (48pesos) Diplomates and Fellows of Specialty Societies 56 pesos for RVU 500 and < 80 pesos for RVU 501 and > Doctors classified as GP shall be compensated up to RVU 80 (3,200 pesos).
  • MD WITH GP DIPLOMATES AND FELLOWS TRAINING Type B, C Type D PCF 40 48 56 80Pyelotomy w/ (4,000) exploration 4,800 5,600 - (100 RVU) 3,200*Myomectomy; (6,000) Open (150 7,200 8,400 RVU) 3,200* Intracranial (24,000) Surgery 28,800 - 48,000 (600 RVU) 3,200* * GP allowed only to do up to 80 RVU
  • Payment of 2 or more procedures surgeonDone in one site or incision Pay only the(whether by same or different surgeon) highest RVUDone in separate site or incision Pay all RVUs(whether done in 1 operative session)Done on different dates Pay all RVUs(within or separate confinement)
  • Anesthesiologist – 40% 0F BASELINE X PCF OF TIER OFANESTHESIOLOGIST  Anesthesiologist’ fee depends on:  RVU of the procedure  PCF depending doctor category (3 tier)  GP (40% of the baseline surgeon’s fee) MD with training (48% baseline) Fellows/diplomates (56 % baseline for RVU 500 and <) Doctors classified as GP shall only be compensated up to RVU 80 (1,280 pesos).
  •  Payment of anesthesiologist is independent of surgeons’ specialty.
  • Table 1: List of Procedures and Services that are Limited to Specific Categories of Doctors ClaimsProcedures and Services Diplomate or Fellow Code Group Philippine Academy of Family 1201 PhysiciansPreoperative inpatient 1202 Philippine College of Physicians consultation 1203 Philippine Pediatric Society (Code 99256 – 99360) 1210 Philippine Neurological Association Pathology services 1206 Philippine Society of Pathologist (Code 88174 – 88332) Radiology services (Code 70010 – 77789 1207 Philippine College of Radiology except 75757) Fluorescein angiography Philippine Academy of 1304 (Code 75757) Ophthalmology
  • CURRENT PF EXPANDED PERCENTAG YEAR’S PHILHEALT WITHOLDIN E TAX (PT) TOTAL TAX PF NET OF GROSS H G TAX (GROSS/1.1 (EWT + PT) TAXINCOME PAYMENT (EWT) 2 X 5%)BELOW (GROSS /720,000 16,000 1.12 X 10%) 714.29 2,142.86 13,857.14WITH 1,428.57SWORNABOVE720,000 (GROSS/1.1OR 16,000 2 X 15%) 714.29 2,857.14 13,142.86NO 2,142.86SWORN
  • CURRENT PF EXPANDED PERCENTAG YEAR’S PHILHEALT WITHOLDIN E TAX (PT) TOTAL TAX PF NET OF GROSS H G TAX (GROSS X (EWT + PT) TAXINCOME PAYMENT (EWT) 3%)BELOW (GROSS X720,000 16,000 10%) 480.00 2,080.00 13,920.00WITH 1,600.00SWORNABOVE720,000 (GROSS XOR 16,000 15%) 480.00 2,880.00 13,120.00NO 2,400.00SWORN
  • Issuance of OR for received PhilHealth payments: Circular 24, s-2005 Doctors should issue OR to PhilHealth upon receipt of reimbursement DKTM
  •  Hospital payment method that reimburses hospitals a predetermined fixed rate for each treated case also called per-case payment or packages Single rate regardless of hospital category and length of stay
  • Case Rates – Surgical Procedures Cases Rates1 Radiotherapy 3,0002 Hemodialysis 4,000 Maternity Care Package (MCP) 8,0003 NSD Package in Level 1 Hospitals 8,000 NSD Package in Levels 2 to 4 Hospitals 6,5004 Cesarean Section 19,0005 Appendectomy 24,0006 Cholecystectomy 31,0007 Dilatation & Curettage 11,0008 Thyroidectomy 31,0009 Herniorrhapy 21,00010 Mastectomy 22,00011 Hysterectomy 30,00012 Cataract Surgery 16,000
  • Case Rates – Medical Cases Cases Rates1 Dengue I (Dengue Fever and DHF Grades I & II) 8,0002 Dengue II (DHF Grades III & IV) 16,0003 Pneumonia I (Moderate Risk) 15,0004 Pneumonia II (High Risk) 32,0005 Essential Hypertension 9,0006 Cerebral Infarction (CVA I) 28,0007 Cerebral Hemorrhage (CVA II) 38,0008 Acute Gastroenteritis (AGE) 6,0009 Asthma 9,00010 Typhoid Fever 14,000 Newborn Care Package in11 1,750 Hospitals and Lying-in Clinics
  • Pursuant to Board Resolution No.1441 s.2011 Case payment mechanism for the most common medical and surgical conditions (49% of total claims)  “No Balance Billing Policy” (NBB) Improve turn-around time for claims processing and payment
  •  Case payment shall be the new reimbursement for all the specified cases Applies to all claims by eligible PhilHealth members and dependents Reimbursed directly to the facility Rates are inclusive of payment to all doctors Computation of doctors’ PF:  Medical : 30% of rate  Surgical : 40% of rate Hospitals shall act as the withholding tax agent for PF Government hospitals  PF governed by the existing rules on pooling (Sec 35 of RA 7875 as amended and its IRR and PC No. 27 s-2009)
  • 1. Provide correct RVS and/or ICD-10 codes in Claim Form 22. Reimbursement shall be based on main condition (PC No. 04, s-2002)3. Rule on 45-day limit per calendar year applies • For hemodialysis and radiotherapy, one (1) day shall be deducted • Outpatient Malaria and HIV-AIDS packages, apply rule on 45- day limit • TB-DOTS excluded from the 45-day limitd Shall follow the rule on single period of confinement • Except for hemodialysis and radiotherapy  per session
  •  “No Balance Billing” Policy shall mean that no other fees or expenses shall be charged or paid for by the patient-member above and beyond the packaged rates.
  • Shallbe applied to ALL SPONSORED Programmembers and/or their dependents for the specifiedcases under the following conditions: 1. When admitted in government facilities/ hospitals. 2. When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and all non- hospital facilities (e.g. FDCs, ASCs)
  • 1. Claims for reimbursement of Sponsored members and/or their dependents availing of the following existing outpatient packages: a) TB DOTS (Php 4,000) b) Malaria (Php 600) c) HIV-AIDS (Php 7,500 /qtr or Php 30,000/yr)  All other existing policies/guidelines covering these packages shall remain in effect.
  • 4. In support of Millennium Development Goals (MDG)  NBB policy shall apply to ALL PhilHealth members and their dependents regardless of membership type in ALL Accredited MCP (non- hospital) providers  This shall cover claims for MCP and NCP
  •  Facility should purchase necessary items/services in advance on behalf of the member if drugs, supplies, or diagnostic procedures are not available. Out-of-pocket payment (OOP) made by members shall automatically be deducted against claims of the hospitals (charged to case rates) with corresponding sanctions or penalties the Corporation may charge. Require attachment of official receipt/s (ORs) for any OOP made by member (for hospital and/or professional fee)
  •  If case rate was already paid in full to the facility; but the official receipts were not attached to the claim application,  the member may request for re-adjustment within 6 months from date of discharge This may be paid to the member provided necessary evidence of payment is submitted It shall be charged to future claims of the health facility with corresponding sanctions or penalties
  • For Claims Not Covered by NBB and Case Rate For Claims of PhilHealth members not covered by NBB Policy The benefit shall be deducted from the total actual charges, with the remaining amount to be charged to the member as out-of-pocket payment. Example: Acute Gastroenteritis = Php 6,000Total Actual PhilHealth Benefit Co-Payment of member ChargesPhp 9,000 Php 6,000 Php 3,000 For all other claims: Fee-for-Service Scheme Based on Benefit Table
  •  Filed within 60 days from date of discharge Still requires ALL existing documents and information Properly accomplished Claim Form 2 Correct RVS/ICD 10 code appropriate for the package
  •  Claims with incomplete documents shall be returned for completion  May be re-filed within 60 days from receipt of notice otherwise it shall be denied  Hospitals to segregate claims with separate transmittals as follows: 1. Case Payment claims 2. Fee-for-service claims
  • Specific Rules Per Package AUGUST 2011
  • Case rate directly paid to the facility 40% of rate is for PF except for hemodialysisAllowed only in L2 to L4 facilities, but some may allowed in other facilities: Completion curettage : L1 Fractional curettage : L1, ASC Herniorrhapy : ASC Laparoscopic chole : ASC Cataract : ASC Hemodialysis : FDC Radiotherapy : L3 to L4 only
  • Emergency procedures in L1 hospitals: Pay as RVU 30 under FFSNon-emergency cases shall be denied Claim Form 3 required for all claims
  • Lateralprocedures within sameconfinement or different confinement within 90 days  pay as 1 2 or more surgical case rates in 1 confinement: 1 session  pay higher package Separate session  pay all packages
  • Transferred patients: Pay referral facility Deny payment of referring facilityExcept for MCP in accredited birthing facilities
  • Maternity Care Package 59401 Payment for the package shall be 8,000 divided as follows: SERVICES COVERED AMOUNTa. Facility fee (including PF) 6,500b. Member’s prenatal care fee 1,500 TOTAL 8,000 The enhanced MCP shall be availed by members in non-hospital facilities accredited as providers of MCP. NBB policy shall apply to all beds in accredited MCP providers.
  • Prenatal care fee directly payable to member Normal deliveries performed requiringemergency and subsequent referral to higher facility is allowed Referring facility (MCP provider) reimbursed fully Referral facility reimbursed based on services rendered
  • No deliveries were completed by MCP facility due to complications: MCP facility pay Php 650 (10% of facilityfee) as reimbursement for services provided
  • Payment for NSD shall be as follows: CostHospitals Facility Fee Prenatal Care TOTAL (with PF) L1 Payment for NSD shall be as follows: 1,500 6,500 8,000 L2 to L4 1,500 5,000 6,500Prenatal care fee directly payable to member
  • Features: @19,000Not allowed in L1 hospitalsElectiveCS (per request) including repeat CS w/o indication  non-reimbursiblePackage covers also (no add’l pay): CS w/ BTL, CS w/ appendectomy, CS with adhesiolysis.
  • Features: @11,000This package is for: L1 to L4 hospitals (58120, 58100, 59812, 59814) ASC (58100, 58120) Excluded: evacuation of H-mole
  • Features: @30,000 This package also covers CS with hysterectomy Not allowed in L1 and ASC Exclusions: vaginal hysterectomy hysterectomy for malignancy
  • Features: @22,000This package applies to surgery done in 1 orboth breastL2 to L4 hospitals onlyRadical mastectomy (19200, 19220, 19240) isexcluded from this package
  • Features: @31,000This package includes all procedures thatremoves a portion or the whole glandL2 to L4 hospitals onlyExclusion: Removal of thyroglossal duct cyst Removal of sinus Removal of parathyroid
  • Features: @24,000This package applies to all appendectomyprocedures including laparoscopicappendectomyL2 to L4 onlyElective appendectomy is non-reimbursible(also denied under FFS)Appendectomy following exploratorylaparotomy is paid as exploratory laparotomy(FFS)
  • Features: @31,000This package applies to all cholecystectomyprocedures, including laparoscopiccholecystectomyL2 to L4 only, laparoscopic cholecystectomyallowed in ASCs
  • Features: @21,000This package covers unilateral or bilateralproceduresAlso includes repair of abdominal and femoralherniaNot allowed in L1Allowed in ASC for repair of reducible, non-incarcerated or non-strangulated hernia
  • Features: @4,000 per sessionOutpatient hemodialysis Includes payment for PF (Php500), dialyzer and epoetinNot allowed in L1 and ASCExcluded (pay under FFS): Hemodialysis during confinements Peritoneal dialysis Treatment of acute renal failure Creation of fistula
  • Features: @3,000 per sessionOutpatient radiotherapy onlyThis package cost is per session onlyAllowed in L3 and L4 onlyExclusions: Treatment planning Brachytherapy Stereotactic surgery
  • Features: @16,000Covers cataract extraction proceduresAllowed in ASC, L2 - L4 onlyDone in an outpatient or inpatient set-upregardless of number of days of confinementCharge 1 day from 45-days limitCovered by single period of confinement
  • Case rate directly paid to the facility 30% of rate is for PFReimbursement will be based on mainconditionIll defined diagnoses (T/C, R/O, probable,suspected) in the final diagnoses shall bedenied even under FFSClaim Form 3 required
  • Provide correct ICD 10 codes up to the last character requirement  Transferred patients: Pay referral facility Deny payment of referring facility o Except for MCP in accredited birthing facilities
  • Newborn Care Package 99432 he package shall be increased to 1,750 pesos t shall include the following services:1. Essential newborn care (Immediate drying of the newborn, early skin-to-skin contact, cord clamping, non-separation of mother/baby for early breastfeeding initiation, eye prophylaxis, Vit. K administration)
  • Newborn Care Package 99432 BCG vaccination,Hepatitis B immunization (1st dose), Professional fee (including breastfeeding advise and physical examination of the baby, among others)2. Newborn screening test (NBS)3. Newborn hearing screening test
  • Newborn Care Package 99432 f services were not provided completely or ifmember was asked to purchase medicines oraccess services outside the facility It shall be reimbursed to the member based on the OR attached and deducted from the payment to the facility
  • Newborn Care Package 99432 f package was paid in full to the facility but uponpost-audit services were not completely given,these shall be charged to future claims of thehealth facility with corresponding sanctions orpenalties the Corporation may charge. ll NCP claims are covered by NBB
  • Features: @8,000This package covers Dengue Fever and DengueHemorrhagic Fever Grades I and IIFor L1 to L4 hospitals Denied (even on fee-for-service): Undifferentiated fever Asymptomatic dengueRequired tests: platelet count, Hgb & Hct
  • Dengue II A91.2, A91.3Features: @16,000This package covers Dengue HemorrhagicFever Grades III and IV Presence of shockFor L2 to L4 hospitals Dengue II managed in L1  TO BE paid as Dengue IRequired tests: platelet count, Hgb & Hct
  • I. PEDIA PNEUMONIADIAGNOSIS(Pedia) ICD-10 CODE Case rate Package PCAP A (minimal risk J18.90 Denied even in PCAP B (lLow risk) J18.91 FFSPCAP C ( Moderate Risk) J18.92 Pneumonia I PCAP D(High Risk) J18.93 Pneumonia IIII. ADULT PNEUMONIA    DIAGNOSIS(Adult) ICD-10 CODE Case rate Package CAP I(Low Risk) J18.91 Denied even in FFS CAP II(Moderate Risk) J18.92 Pneumonia I CAP III(High Risk) J18.93 Pneumonia II
  • Features: @15,000This package covers adult and pediatric caseswith unstable vital signs and presence of co-morbid conditionFor L1 to L4 hospitalsDenied: Low risk pneumonia (no payment even on FFS)Required tests: chest X-ray
  • Features: @32,000 This package covers adult and pediatric cases with unstable vital signs and presence of co- morbid condition PLUS shock or signs of hypoperfusion: Hypotension I95.9  Hypercapnea R06.4 Hypoxia I24.8
  • Pneumonia II claims without additional codes for signs of shock or hyperperfusion shall be reimbursed as Pneumonia I for L2 to L4 hospitals; L1 to be paid as Pneumonia IRequired tests: chest X-ray
  • Features: @9,000This package covers hypertensive emergencycases requiring admissionExclusion (to be paid under FFS): Hypertension involving vessels of the brain, eye Cases of secondary hypertension
  • CVA I (Infarct)  CVA II (Bleed)Features: @28,000 Features: @38,000  This package covers This package covers hemorrhage I60.- I61.-, infarct I63.-, I64.- I62.- L1 to L4  L2 to L4  CVA II in L1 hospitals to be Requirements: paid as CVA I 1. neuro exam  Requirements: 1. neuro exam, 2. CT ScanExclusions:2.CVA requiring neurosurgery3.TIA (G45.9), occlusion stenosis not resulting to infarction I65 – I69
  • Features: @9,000This package covers persistent and severecases of asthma requiring admission in adultand pedia Excluded (pay as FFS): status asthmaticus (J46)as well as ICD 10 Codes: J82, J60-J70Denied (even on FFS): asthma not in acuteexacerbation
  • Features: @14,000 This package covers:  Typhoid and paratyphoid fever  Other salmonella infection  Typhoid (infective) psychosis L1 to L4 Exclusion (pay as FFS): typhoid ileitis requiring surgery Requirement: result of typhidot or Widal test
  • Features: @6,000This package covers (infectious/non-infectious) diarrhea with moderate or severe dehydration; &, patients who remain dehydrated despite initial treatment Children with bloody diarrhea and severe malnutrition Denied: AGE with NO or SOME signs ofdehydration (no pay even on FFS)
  • Features:Required additional codes: E86.1 - moderate dehydration E86.2 - severe dehydrationAbsence of additional codes - DENIEDRequired diagnostic: fecalysis or culture
  • Top 20 illnesses ranked by Number of Claims Paid RANK 1 September 2011-April 2012 Description HEMODIALYSIS NO OF CLAIMS 111,270 AMOUNT PAID 432,013,770.42 2 ACUTE GASTROENTERITIS (AGE) 32,994 197,321,923.28 3 PNEUMONIA I 28,320 423,129,327.56 4 NSD 16,233 83,112,660.24 5 NCP 14,860 23,974,558.32 6 CAESARIAN SECTION 14,265 269,885,467.04 7 RADIOTHERAPHY 13,285 36,223,168.98 8 ESSENTIAL HYPERTENSION 13,174 117,985,361.80 9 CATARACT 10,777 172,220,658.67 10 ASTHMA 7,855 70,389,360.49 11 DENGUE I 7,451 59,260,427.58 12 DILATION AND CURETAGE 6,003 65,340,127.88 13 TYPHOID FEVER 4,908 68,509,585.70 14 MCP 4,388 33,090,617.23 15 CHOLECYSTECTOMY 3,064 94,404,975.77 16 CVA I (INFARCTION) 2,958 81,652,434.91 17 APPENDECTOMY 2,748 65,675,149.63 18 HYSTERECTOMY 1,602 47,828,863.30 19 HERNIORRHAPY 1,054 22,022,076.95 20 THYROIDECTOMY 770 23,717,528.11 SOURCE: PHILHEALTH N CLAIMS DATABASE Extracted date: May 8, 2012
  • s Late filing = 17%s Inconsistent data on forms submitted = 4.37%Documents must be submitted within 60 days from discharge: PhilHealth Form 1 (member & employer) PhilHealth Form 2 (doctor & hospital) PhilHealth Form 3 (doctor & hospital as required in primary hospitals)
  • s Not accredited hospital = 11%s < 24 hours confinement, non “E” = 1.2% confinement in an accredited hospital of not less than 24 hours
  • s > 45 days allowance, benefit exhausted = 10.21%s Lack of qualifying contribution = 1.10% the 45-days allowance for room and board has not been consumed yet at least 3 consecutive monthly contributions within the immediate 6 months prior to admission
  • s Non-compliance to RTH request = 5.25% Claims with incomplete requirements shall be returned to the facility and must be complied within 60 days Non-compliance shall cause denial of claim
  • Most Common Reasons of RTHOB Record/OR Record/Surgical Record/Anesthesia Record 10,945 31.18Not properly accomplished PhilHealth Forms 1, 2 & 3 6,493 18.5Submit PhilHealth Form 3/Clinical Chart 2,860 8.14Birth Certificate of Member 2,081 5.93Submit affidavit (dependents) 1,606 4.57Hospital waiver/Official Receipts 1,529 4.35Duly validated MI-5 (applicable qtr.) 1,498 4.26PhilHealth ID Card (Sponsored and NPM) 1,460 4.16Birth Certificate of patient (No MDR) 1,203 3.43
  • 1301-9805998-7 1301-0200190-3 Dr. Edgardo R. Cortez  Dr. Genevieve P- ◦ MD Evangelista ◦ Cutting Specialist ◦ MD ◦ PCS ◦ Cutting Specialist ◦ PCS 12 10 -9501093-8 120 7 -9804494-1• Dr. Joven R. Cuanang • Dr. Angelito Tingcungco – MD – MD – Non-Cutting Specialist – Non-Cutting Specialist – PNA – PCR
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  •  Payment system in which health care providers receive payment for each unit of service Expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one Benefits depend on: Hospital/Doctor category Case type of Illness Length of stay Needs itemization; benefits determined retrospectively
  • Fee-for-Service Advantages DisadvantagesGreater flexibility on Incentive for supplier – inducedmanagement of patients by demand ( increased services,doctors; low financial risk to increased length of stay,HCP unnecessary intervention) High administrative cost for hospitals and PhilHealth High financial risk to payors (PhilHealth and members) Incentive for fraud (creeping) Retrogressive – high out-of- pocket payment for catastrophic cases
  •  Internationally accepted payment mechanism Beneficial for members, providers and the Corporation Members will be able to predict PhilHealth benefit since it is more transparent Improve turn-around time for claimsprocessing Better cost efficiency and faster reimbursements 128
  • Case Payment Scheme Advantages DisadvantagesLess administrative cost forhospitals and PhilHealth Increase admission(Needs no itemization) Under-utilization of services • Patients to buyFaster payment of claims supplies/drugs • Premature discharge of patientsModerate financial risk toPhilHealthHigh financial protection to allPhilHealthmembers/beneficiaries
  •  Compliance Monitoring PhilHealth shall regularly monitor compliance with implementing guidelines to be issued Penalties and Sanctions Violators shall be meted the appropriate sanctions and penalties available to the Corporation Violators shall be included in the Provider Assessment Monitoring System (PAMS) and will be subjected to warranties of accreditation Shall be reported to DOH and/or PRC for appropriate action, when necessary Periodic Review, Evaluation and Adjustments Case rates, processes and the No Balance Billing policy shall be subjected to regular evaluation and adjustments, as necessary To be done 6 months after effectivity, then yearly thereafter