Question & AnswerQ&A (PHILHEALTH CIRCULAR NO. 0031, S. 2013)
The main objective is to phase out the Fee-For-Service (FFS) payment mechanism and shift to Case-Based Payment or Case Rates to promote financial protection, equitable basic benefits, and administrative efficiency.
The emphasized guiding principles include Universality, Equity, Effectiveness, Cost Sharing, and Cost Containment as stated in Article 1 Section 2 of Republic Act 7875.
Case-Based Payment is a payment method reimbursing health care providers a predetermined fixed rate for each treated case or disease, also called per case payment.
The Case Rate covers all fees including health care professionals' fees, facility charges such as room and board, diagnostics, laboratories, drugs, medicines, supplies, operating room fees, and other related charges.
Sponsored Members are those whose contributions are paid by another individual, government agency, or private entity as prescribed by PhilHealth rules.
NBB means no additional fees or expenses shall be charged or paid by the patient-member above the packaged Case Rate for indigents and sponsored sectors in government health care institutions.
Direct filing by members is allowed only under certain circumstances as prescribed by PhilHealth rules and guidelines.
Violations will be met with penalties and sanctions pursuant to R.A. 7875 as amended by R.A. 10606, PhilHealth's IRR, and other applicable issuances; penalties may include charging sanctions to future claims and reporting to agencies like DOH and PRC.
HCI shall receive Case Rate payments and are accountable for services provided to PhilHealth members, including facilitating timely payments to health care professionals, credentialing of doctors, and compliance with NBB policy.
Case Rate payments apply uniformly to all medical conditions, procedures, and selected day surgeries admitted or done in accredited health care institutions, regardless of member category.