Case rates presentation gen rules

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 CLAIMS
JOSE R. REYES MEMORIAL MEDICAL CENTER 330
UNIVERSITY OF STO. TOMAS HOSPITAL 305
CHINESE GENERAL HOSPITAL & MEDICAL CENTER 274
UNIVERSITY OF STO. TOMAS HOSPITAL 136
METROPOLITAN MEDICAL CENTER 130
GAT ANDRES BONIFACIO MEMORIAL MEDICAL CENTER 129
MCU-FDT MEDICAL FOUNDATION HOSPITAL 86
CARDINAL SANTOS MEDICAL CENTER 80
PERPETUAL HELP HOSPITAL 78
F.Y. MANALO MEDICAL FOUNDATION - NEW ERA GENERAL HOSPITAL 76

MAKATI MEDICAL CENTER 489
UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER,
INC. 322
FORT BONIFACIO GENERAL HOSPITAL 257
UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER,
INC. 221
TAGUIG-PATEROS DISTRICT HOSPITAL 122
MPI-MEDICAL CENTER MUNTINLUPA 121
RIZAL MEDICAL CENTER 118
ST. LUKE'S MEDICAL CENTER - GLOBAL CITY 110
THE MEDICAL CITY 104
MPI-MEDICAL CENTER MUNTINLUPA 103

K Original Philhealth Claim Form 2 not properly accomplished
l Required medical documents
Required claim form (s)
o Other documents required
r No proof of contribution.
r Original Philhealth Claim Form 3 not properly accomplished
l No proof of Professional fee billing/payment
e Discrepancies
e No proof of hospital billing/payment
i No proof of dependency

1. Filed beyond 60 days
2. Exhausted 45 compensable days
3. Case not compensable
4. Benefit exhausted
5. Denied due to non-compliance
6. Inconsistent data
7. Patient not a qualified dependent
8. Confinement not within the hospital accreditation period
9. Less than 24 hours confinement, case not emergency
10. Lack of/no qualifying contribution

PhilHealth does not pay for all your health care
costs.
PhilHealthpays only for covered items and
services when requirements are met
Members are balance billed for the portion of
the actual cost that is not covered by PhilHealth

ENHANCED
CLAIMS FORMS
Circular 12, s-2010

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 1100

MARIO A. CRUZ MANAGER 09 04 2010

The 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 2
Beginning September 01, 2010

PART I – HEALTH CARE PROVIDER INFORMATION

5,000.00 5,000.00

For benefit packages not requiring itemization PHIC
benefit should be indicated in 11e

DR. PEDRO A. GOMEZ
09/05/10
1 502 1 2 3 4 5 6 1

PART I – PATIENT’S CLINICAL RECORD

This 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 ADMISSIONS
This is mandatory in:
 Level 1 Facilities;
 Case type D;
 Maternity Care Package;
 Emergency / Transferred cases; and
 Less than 24 hours confinement

PART II – MATERNITY CARE
PACKAGE
CF3 shall be accomplished for
MCP claims (lying-in clinics) and
must be submitted together with
CF1 and CF2

9 months
premium within
12 months prior
to admission (on
selected surgical
cases)

Eligibility
Requirements

Qualifying Contributions / Eligibility
Requirements:
Employed /
KASAPI

3 months within
the immediate 6
months prior to
availment

Properly
accomplished Part
II of CLAIM FORM
1

Requirements:
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 DEC

O N D J F M A M J J A S
AVAIL
C O E A E A P A U U U E
MENT
AVAILMENT
T 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

Requirements:
OFW

MDR
(eligibility /
coverage is
reflected)

Requirements:
Sponsored

PhilHealth
Sponsored ID 19-123456789-1

(eligibility / JUAN A. DELA CRUZ
coverage is
reflected)
OCT 13, 2010 – OCT 12, 2011

Requirements:
NPM

PhilHealth Non-
Paying ID or
Lifetime
Member ID

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 Confinement
Benefit 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
l

A 80 and
Simple
below

B Moderate 81- 200

C Severe
201-
500

D 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/day
Drugs and
Medicines** P4,200 P14,000 P28,000 P40,000

X-ray, Lab & Others P3,200 P10,500 P21,000 P30,000

Level 2 Hospital (Secondary)
Room & Board* P400/day P400/day P600/day N/A

Drugs and
Medicines** P3,360 P11,200 P22,400 N/A

X-ray, Lab & Others P2,240 P7,350 P14,000 N/A

Level 1 Hospital (Primary)
Room & Board* P300/day P300/day N/A N/A
Drugs and
Medicines** P2,700 P9,000 N/A N/A

X-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 Doctors
Room/Board Center
P500/day Hospital
P400/day Hospital
P300/day
Drugs P4,200 P3,360 P2,700
Lab/Supplies P3,200 P2,240 P1,600

Benefit Item Makati Fort Bonifacio Taguig
medical General Doctors
Center Hospital Hospital
Room/Board P500/day P400/day x
Drugs P14,000 P11,200 x
Lab/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
Medicines
Drugs must be written in generic name
PNDF is main reference for payment

To 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 Tertiary
1,600 – 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 Hospital
RVU 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 Hospital
RVU 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

Daily Visit
Primary Hospital
A B
GP per day 300 400
Maximum per 1,200 2,400
confinement
SP 500 600
Maximum per 2,000 3,600
confinement

Secondary Hospital
A B C
GP per day 300 400 500
Maximum per
confinement 1,200 2,400 4,000
SP 500 600 700
Maximum per
confinement 2,000 3,600 5,600

Tertiary Hospital
A B C D
GP per day 300 400 500 600
Maximum per
confinement 1,200 2,400 4,000 6,000
SP 800
Maximum per
confinement 8,000

Maximum A B C D
days per
confinemen 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 80
Pyelotomy 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
surgeon

Done in one site or incision Pay only the
(whether by same or different surgeon) highest RVU

Done 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 OF
ANESTHESIOLOGIST

 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

Claims
Procedures and Services Diplomate or Fellow
Code Group

Philippine Academy of Family
1201
Physicians
Preoperative
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) TAX
INCOME PAYMENT (EWT) 2 X 5%)

BELOW
(GROSS /
720,000
16,000 1.12 X 10%) 714.29 2,142.86 13,857.14
WITH
1,428.57
SWORN

ABOVE
720,000 (GROSS/1.1
OR 16,000 2 X 15%) 714.29 2,857.14 13,142.86
NO 2,142.86
SWORN

CURRENT PF EXPANDED PERCENTAG
YEAR’S PHILHEALT WITHOLDIN E TAX (PT) TOTAL TAX PF NET OF
GROSS H G TAX (GROSS X (EWT + PT) TAX
INCOME PAYMENT (EWT) 3%)

BELOW
(GROSS X
720,000
16,000 10%) 480.00 2,080.00 13,920.00
WITH
1,600.00
SWORN

ABOVE
720,000 (GROSS X
OR 16,000 15%) 480.00 2,880.00 13,120.00
NO 2,400.00
SWORN

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 Rates
1 Radiotherapy 3,000
2 Hemodialysis 4,000
Maternity Care Package (MCP) 8,000
3 NSD Package in Level 1 Hospitals 8,000
NSD Package in Levels 2 to 4 Hospitals 6,500
4 Cesarean Section 19,000
5 Appendectomy 24,000
6 Cholecystectomy 31,000
7 Dilatation & Curettage 11,000
8 Thyroidectomy 31,000
9 Herniorrhapy 21,000
10 Mastectomy 22,000
11 Hysterectomy 30,000
12 Cataract Surgery 16,000

Case Rates – Medical Cases
Cases Rates
1 Dengue I (Dengue Fever and DHF Grades I & II) 8,000
2 Dengue II (DHF Grades III & IV) 16,000
3 Pneumonia I (Moderate Risk) 15,000
4 Pneumonia II (High Risk) 32,000
5 Essential Hypertension 9,000
6 Cerebral Infarction (CVA I) 28,000
7 Cerebral Hemorrhage (CVA II) 38,000
8 Acute Gastroenteritis (AGE) 6,000
9 Asthma 9,000
10 Typhoid Fever 14,000

Newborn Care Package in
11 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 2
2. 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 limit

d 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 Program
members and/or their dependents for the specified
cases 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 6,000
Total Actual
PhilHealth Benefit Co-Payment of member
Charges
Php 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 same
confinement 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 facility
Except for MCP in accredited birthing
facilities

Maternity Care Package
59401
Payment for the package shall be 8,000 divided as
follows:
SERVICES COVERED AMOUNT
a. Facility fee (including PF) 6,500
b. 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 requiring
emergency 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 facility
fee) as reimbursement for services provided

Payment for NSD shall be as follows:
Cost
Hospitals 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 6,500

Prenatal 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 or

both breast
L2 to L4 hospitals only
Radical mastectomy (19200, 19220, 19240) is

excluded from this package

Features: @31,000
This package includes all procedures that

removes 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 appendectomy

procedures including laparoscopic
appendectomy
L2 to L4 only

Elective appendectomy is non-reimbursible

(also denied under FFS)
Appendectomy following exploratory

laparotomy is paid as exploratory laparotomy
(FFS)

Features: @31,000
This package applies to all cholecystectomy

procedures, including laparoscopic
cholecystectomy
L2 to L4 only, laparoscopic cholecystectomy

allowed in ASCs

Features: @21,000
This package covers unilateral or bilateral

procedures
Also includes repair of abdominal and femoral

hernia
Not allowed in L1
Allowed in ASC for repair of reducible, non-

incarcerated or non-strangulated hernia

Features: @4,000 per session
Outpatient hemodialysis
Includes payment for PF (Php500), dialyzer and
epoetin
Not allowed in L1 and ASC
Excluded (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-up
regardless 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 main
condition
Ill
defined diagnoses (T/C, R/O, probable,
suspected) in the final diagnoses shall be
denied 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)

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

99432


f services were not provided completely or if
member was asked to purchase medicines or
access services outside the facility
 It shall be reimbursed to the member based on
the OR attached and deducted from the
payment to the facility

99432


f package was paid in full to the facility but upon
post-audit services were not completely given,
these shall be charged to future claims of the
health facility with corresponding sanctions or
penalties the Corporation may charge.

ll NCP claims are covered by NBB

Features: @8,000
This
package covers Dengue Fever and Dengue
Hemorrhagic 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, A91.3

Features: @16,000
This package covers Dengue Hemorrhagic
Fever Grades III and IV
Presence of shock
Dengue II managed in L1  TO BE paid as
Dengue I
Required tests: platelet count, Hgb & Hct

I. PEDIA PNEUMONIA
DIAGNOSIS(Pedia) ICD-10 CODE Case rate Package
PCAP A (minimal risk J18.90 Denied even in
PCAP B (lLow risk) J18.91 FFS
PCAP C ( Moderate Risk) J18.92 Pneumonia I
PCAP D(High Risk) J18.93 Pneumonia II

II. 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 cases
with unstable vital signs and presence of co-
morbid condition
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 emergency
cases 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 Scan
Exclusions:
2.CVA requiring neurosurgery
3.TIA (G45.9), occlusion stenosis not resulting to infarction I65 – I69

Features: @9,000
This package covers persistent and severe
cases of asthma requiring admission in adult
and pedia
 Excluded (pay as FFS): status asthmaticus (J46)
as well as ICD 10 Codes: J82, J60-J70
Denied (even on FFS): asthma not in acute
exacerbation

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 of
dehydration (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 RTH
OB Record/OR Record/Surgical Record/Anesthesia Record 10,945 31.18

Not properly accomplished PhilHealth Forms 1, 2 & 3 6,493 18.5

Submit PhilHealth Form 3/Clinical Chart 2,860 8.14

Birth Certificate of Member 2,081 5.93

Submit affidavit (dependents) 1,606 4.57

Hospital waiver/Official Receipts 1,529 4.35

Duly validated MI-5 (applicable qtr.) 1,498 4.26

PhilHealth ID Card (Sponsored and NPM) 1,460 4.16

Birth 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 Disadvantages
Greater flexibility on Incentive for supplier – induced
management 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 claims
processing
Better cost efficiency and faster
reimbursements

128

Case Payment Scheme
Advantages Disadvantages
Less administrative cost for
hospitals and PhilHealth Increase admission
(Needs no itemization)
Under-utilization of services

• Patients to buy
Faster payment of claims
supplies/drugs
• Premature discharge of
patients
Moderate financial risk to
PhilHealth

High financial protection to all
PhilHealth
members/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

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