QuestionsQuestions (PHIC PHILHEALTH CIRCULAR NO. 17)
It discontinues PhilHealth compensability of cataract surgery claims performed during medical missions and through other recruitment schemes, and further limits the number of compensable cataract surgery claims under the program.
PhilHealth Board Resolution No. 1046 s. 2007 is cited as the basis for the discontinuance and limiting measures.
Claims for cataract operations performed during medical missions and other recruitment schemes are discontinued from compensability.
It directs PhilHealth to employ measures to limit the number of compensable claims by ascertaining the veracity of volume claims prior to processing and payment.
PhilHealth must verify whether the reported volume of claims is genuine/valid before approving processing and payment, to prevent or limit excessive or potentially improper claim submissions.
It takes effect on all cataract operation claims with admission dates starting November 1, 2007.
The cutoff is based on the date of admission for the cataract surgery, not necessarily the date the operation was performed or the date of filing.
Based on the text, it applies to claims with admission dates starting November 1, 2007; thus claims admitted before that date would generally not fall under the new discontinuance/limitation.
All other issuances inconsistent with Circular No. 17 are “hereby repealed and modified accordingly.”
It would need to determine whether the surgery was performed during a “medical mission” or “through other recruitment schemes,” since those are expressly discontinued from compensability.
Patients may no longer receive PhilHealth reimbursement/coverage for those specific cataract surgery claims, and providers may not be paid by PhilHealth for claims falling under the discontinued categories.
Because it aims not only to stop compensability for certain recruitment contexts (medical missions/recruitment schemes) but also to prevent excessive or unverified high-volume claim submissions by requiring verification before payment.
It indicates the Circular is mandatory and binding on stakeholders, requiring adherence to the discontinuance and limiting measures without discretionary deviation.
It was signed by Lorna O. Fajardo, Acting President and CEO; it implies the authority of the PhilHealth executive leadership to issue implementing policy under the board resolution.