The New Cataract Payment Scheme

New cataract claim payment scheme
By: Larry Tabsing

PhilHealth payment of cataract extraction procedures shall now be on a case payment basis. The new policy has been laid down through PhilHealth Circular No. 16 2009 recently released by PhilHealth. This will be applicable to availment starting May 1, 2009.

The new cataract package has a case payment scheme wherein claims arising from a cataract extraction procedures shall be paid P16,000 pesos regardless whether the procedure was done in one or both eyes in one operative session.

This payment scheme applies to all applicable health care providers for cataract surgery in an ambulatory surgical clinics, and in secondary or tertiary hospitals, whether done in outpatient or inpatient set up regardless of number of days of confinement. However, cataract procedures covered under this package are limited only for intracapsular cataract extraction with insertion of intraocular lens prosthesis; extracapsular cataract removal with insertion of intraocular lens prosthesis like irrigation and aspiration; and, phacoemulsification.
For this, P8,000 is payment for hospital charges for room and board, drugs and medicines used during confinement, x-ray, laboratory and ancillary procedures done during confinement and use of operating room complex and machines. While the other P8,000 goes to professional fee of doctor who performed the procedure.

Excluded in the package are payment for preoperative tests done prior to confinement, professional fee for preoperative consultation and/or physician standby service as well as the anesthesia service, and complex cataract surgery requiring techniques not generally used in routine cataract surgery or performed on patients in the amblyogenic developmental stage.
In claims filing, in cases where members are required by hospitals to buy drugs, medicines and supplies or required to seek out other necessary services like laboratory procedures from other facilities, reimbursements to members is allowed if the facility cannot provide the necessary items and services covered by the benefit but these have been used during confinement. Members have to submit official documents and/or other purchased documents. Reimbursements however depend on the actual cost of the receipts submitted but not more than the difference between the maximum benefit and the facility reimbursement