QuestionsQuestions (PHILHEALTH CIRCULAR NO. 0031, S. 2013)
The circular cites Article 1, Section 2 of Republic Act (RA) No. 7875, as amended, which sets guiding principles for PhilHealth in pursuing the National Health Insurance Program (NHIP), including universality, equity (uniform basic benefits), effectiveness, cost sharing, and cost containment.
It states that FFS has intrinsic constraints and may lead to prolonged hospital stays, overutilization of diagnostic procedures, provision of unnecessary/inefficient services, wasteful payments, and inequities (e.g., beneficiaries may get higher reimbursements in private vs. government facilities for similar conditions).
To phase out fee-for-service; simplify reimbursement rates for all sectors; and improve turnaround time (TAT) of claims processing.
Case rate payments shall be uniformly applied to all medical conditions and procedures, regardless of member category, that are admitted in accredited health care institutions (HCIs); and also to identified day surgeries and select procedures performed in accredited HCIs.
Yes. Direct filing by members is allowed only for certain circumstances prescribed by PhilHealth and subject to compliance with rules on direct filing.
Case-based Payment is a method that reimburses health care providers a predetermined fixed rate for each treated case/disease (per case payment). Case Rate (CR) is the fixed amount PhilHealth will reimburse for a specific illness/case, covering professional fees and facility charges (e.g., room and board, diagnostics, labs, drugs, operating room fees, and other charges).
No Balance Billing means no other fees or expenses shall be charged or paid by the patient-member beyond the packaged rates. It applies to all indigents and sponsored sectors.
The circular states that it is incumbent upon the HCI to deduct the entire CR amount from the patient’s total hospitalization/facility bill, including professional fees, at all times.
The claim shall be reimbursed if there is at least one (1) PhilHealth-accredited doctor managing the case. If the services were provided by non-PhilHealth accredited professionals/doctors ONLY, the claim shall be denied.
It states that PhilHealth shall endeavor to pay for all admissible medical conditions and/or procedures subject to limits set by the PhilHealth Board, and that a separate circular shall be issued to detail how payments to multiple cases shall be made.
All CR payments shall be paid to account of the HCI. The HCI must facilitate payment to health care professionals not exceeding 30 calendar days upon receipt of reimbursement (or a time frame agreed by facility management and professionals). The HCI must also file claims within the prescribed period of filing (60 days).
No. It provides that credentialing and privileging of doctors and other health care professionals shall be delegated to the concerned HCI, and PhilHealth shall no longer have tiered payments according to training or specialization.
The HCI must withhold the expanded withholding tax as per BIR policy on payments to doctors/medical practitioners for their professional fees, and withhold the final VAT on Government Money Payment (GMP), if applicable. It also states PhilHealth shall withhold income tax as per BIR policy against the case rate amount to be paid to the HCI.
PhilHealth’s database must be designed and improved to generate real-time, quality, and responsive information/evidence used for evidence-based policy development and rate adjustments.
Compliance shall be regularly monitored and evaluated, and post-audit evaluation shall be conducted on CR claims subject to rules of existing post-audit implementing guidelines.
It takes effect fifteen (15) days after publication in any newspaper of general circulation, and must be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.
It states that violations shall be meted the appropriate penalty and sanctions pursuant to RA 7875, as amended by RA 10606, its IRR, and applicable PhilHealth issuances. It also provides that violations may be included in provider performance under PEACHeS and charged to future claims of the HCI, with furnishing of the decision to DOH, PRC, and/or other concerned agencies.