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

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

PhilHealth personnel plant trees

PhilHealth cites 8 Iloilo LGUs for universal coverage

PhilHealth cites 8 Iloilo LGUs for universal coverage
By: Larry T. Tabsing

PhilHealth recognized 8 local government units in the province of Iloilo for enrolling more than the targeted poor families for universal coverage to the National Health Insurance program.

The Municipality of Bingawan topped as the most number of sponsored indigent households of 274% followed by San Enrique (208%) and Mina (203%).Then Concepcion, Barotac Viejo, Banate, Batad and Badiangan. All of their mayors personally received the recognition except for Concepcion and Batad.

There are about 18 LGUs that have enrolled more than the targeted poor families but PhilHealth on this focused on LGU initiated universal enrollments less the provincial and legislative sponsorship.

There are about 90,859 poor families in the Province (based on the 2006 NSCB data net of the 21,204 poor families in Iloilo City). As of December 2008 there were already 70,982 poor families enrolled into the Program (inclusive of the provincial, municipal and legislative enrollment). About 19,877 poor families needs to be enrolled into the program, which is now the target to cover before October 2009.

Regional Vice President Alberto C. Manduriao said that the intention of the Program is to ensure that the poor will have free access to quality health service and make the members and theirs dependents feel they are secured. “In times that someone in the family get sick they are assured that they can get quality health care services in any of the PhilHealth accredited health care facilities and confident that their hospital bill will be taken cared of”, he noted..

Addressing the Local Chief Executives RVP Manduriao stresses, “Through you, their local official, you have given them back their sense of dignity as a human being for they will no longer be afraid or ashamed of entering a hospital if they need medical service”.

Manduriao challenged the health workers asking why PhilHealth member has to go to the hospital when the illness can be prevented and treated in the RHU. “Baka walang tiwala mga tao magpagamot sa RHU dahil siguro, wala lagi si Doc? Wala o kulang ang gamut at mga gamit sa RHU, masungit ang nurse? O baka naman walang health program sa RHU kaya ganun!, he surmised. “We still believe that Health is Good Governance; Health Good Investment and Health is Good Politics”, he stressed.

Under the Sponsored - Indigent Program, in every family a LGU enrolled, PhilHealth pays back P300 as Capitation payment to augment their budget or fund for health services; ensure that indigents are given quality out-patient service in the RHU. The 80% of the Capitation fund to purchase drugs, medicines, medical, laboratory and dental supplies, equipment and even for the repair and renovate your health facility if necessary.

RHU can be accredited under the 3 in 1 scheme - the OPB, MCP and TB-DOTs. PhilHealth is paying an additional P4,500.00 for every normal delivery (member can claim up to 4 normal spontaneous delivery), P1,000.00 for the new-born care package and P4,000 for every treated TB patient.

Infact, the amount due to the different LGUs in Iloilo as Capitation payment is P15.5M , but paid only P1.76M not because it does not have the money but simply because certain Municipal Health Officers and Municipal accountants are not submitting the required monthly Reports and the Capitation utilization report which are pre-requisite to support the release of the remaining P13.8M.
The recognition was done during the Semana sa Iloilo at the Provincial Health sponsored Hospital Operations and Services awards.

PhilHealth commended universally covered municipalities in Iloilo

PhilHealth President meets Iloilo Press people

35% increase in PhilHealth Benefit Payment

MORE THAN 69 million members of Philippine Health Insurance Corporation (PhilHealth) nationwide will enjoy increase in in-patient care benefit ceilings for confinements starting April 5 this year.

"We have recognized the fact that rapid inflation has somehow reduced the significance of our existing benefit levels. There is an urgent need therefore to adjust our subsidies to meet the rising cost of hospitalization among our members," said Dr. Rey B. Aquino, PhilHealth President and CEO. Substantial increase in subsidies for hospitalization fees and professional charges of physicians, in response to the emerging and re-emerging of diseases and other health conditions in the country albeit the escalating cost of hospitalization, is expected to reach at 35 percent increase on annual benefit payments of the corporation.

In the 2009 revised in-patient benefit schedule, items such as subsidy for room and board, drugs and medicines, x-ray, laboratories and supplies and payment for professional fees of accredited physicians (including surgeons and anesthesiologists) have increased significantly, without any corresponding increase in premium contributions by members.

In the benefit item for room and board, confinement at the tertiary level hospitals will now have a subsidy of 500 pesos to 1,100 pesos per day depending on the case/type of illness as compared to the 400 pesos to 1,035 pesos subsidy. Though the increase in allowances for hospital room and board fees is moderate, a 260 percent increase in drugs and medicines for Case Type B in Primary Hospital is demonstrated, from P2,500.00 to P9,000.00 per single period of confinement. Such amount (P9,000.00) was then the maximum ceiling for drugs and medicines in Tertiary Level hospital under Case B category of illness. Rules on Philippine National Drug Formulary (PNDF), Antimicrobial Resistance Surveillance Program (ARSP) and rational drug use shall be observed.

With the new in-patient package, payment for x-ray, supplies, laboratory & other ancillary procedures grew as much as 76 percent. Additionally, maximum benefit for supplies and radiology, laboratory and ancillary procedures shall depend on hospital category and case type of illness and shall be covered by the rule on single period of confinement.

On the other hand, payment for operating room (OR), for patients undergoing surgical procedures will depend on the category of hospital and the RVU (Relative Value Unit) of the procedure. In the case of primary hospital, payment for OR is fixed at 500 pesos per use of operating room. However, P750.00 to a maximum of P7,500.00 OR fee shall be paid to ambulatory surgical clinics (ASC), freestanding dialysis centers and to hospitals depending on its category and RVU of the given procedure.

Further, maximum amount for professional fees both of the general practitioners and specialists combined rose up to 136 percent. "These benefits were increased in varying degrees across all case types (or illness types) as applicable, in participating tertiary, secondary and primary hospitals in the country," Aquino stressed. Likewise, consequent increase for anesthesiologist and surgeon's fees were also included based on PhilHealth's recently approved tiered payments for professional fees and the revised valuations for certain surgical and medical procedures.

Amid this significant move by the corporation to increase its benefits for in-patient care, its 1,500 partner hospitals are also called to continuously better their services and abstain from unnecessary jacking up of their fees so that PhilHealth members can fully enjoy these increases in benefits, added Aquino. (PRO VI-PAU)

Tree Planting

PhilHealth ID distribution in Capiz

Check Replacement

PhilHealth observed that several benefit payment checks are still under the name of the deceased member and members who are outside of the country, hence, cannot be encashed and consequently had staled.

“It’s only when proper and valid documents to support a claim for check replacement that we can change the payee of the check”, explained by Roberto Dais, PhilHealth in-charge for check replacement, “without such, the check is generated on the member’s name.”

The problem usually happens on claims of deceased member, who died while confined or after discharged from the hospital but with pending claims because of previous hospitalization.
The check can be changed to the new payee but rightful claimant must first comply with the needed requirements such as the member’s death certificate as well as member-claimant proof of relationship.

Priority is given to those listed as dependents in the Member Data Record (MDR), from spouse to any of the child/ren authorized by the other siblings and biological parents. If member has no direct heir, a collateral relative may proceed to claim.

As to members who are abroad, check usually stales because their spouse cannot claim the same. “Common reason is, they alleged to have no joint accounts in bank wherein the check could be deposited, so they just await for the return of their member-spouse”, Dais added.

Under PhilHealth policy, benefit payment check is generally issued to the member. And only under two conditions: when payee is deceased or is out of the country, that replacement is allowed to the legitimate claimant.

A Special Power of Attorney granting authority to do PhilHealth transactions is one of the easy proofs. In its absence, the rightful claimant must submit a request and proof of member’s status abroad. Claimant has still to provide valid identification, IDs of both member and claimant. PhilHealth noted certain cases that spurious claimant faked the documents in order to claim.PhilHealth Regional Office VI head Alberto C. Manduriao stressed that members who understand their rights and complied their responsibilities do not find difficulty in processing and claiming PhilHealth benefits. So PhilHealth encourages members and dependents to be informed of these.