Rules on Reimbursement of Professional Fees for Pooling

Claims signed by Medical Director, Hospital Administrator (if a physician), or Department Heads for salaried physicians in designated hospitals can be compensated.
Daily visit fees are based on non-specialists’ rates.
A Professional Conversion Factor (PCF) of 40 is used regardless of the accreditation category for claim computation.
Exception: When hospital officials provide the service themselves (documented accordingly), PF is computed per their accreditation category.

Certain procedures/services are restricted to doctors accredited under specific professional groups (e.g., family physicians, pathologists, radiologists, ophthalmologists).
Claims for PFs by unauthorized doctors for these services are disallowed.
Pooling claims signed by hospital officials on behalf of salaried physicians are eligible using PCF 40.
If hospital officials personally rendered the service and meet accreditation requirements, PCF 56 is used.
If an accredited doctor other than the Medical Director signs the claim:
- PFs follow the rules in the specified services list.
- PCF 56 is used if the doctor is authorized for that service.
- Claims are denied if the doctor’s accreditation does not authorize the service.

General practitioners (GPs) classified as Group 1 receive payment capped at 80 RVU for surgeries and linked services in Level 2-4 hospitals.
Maximum payments: PHP 3,200 for surgeries/RVU services, PHP 1,280 for anesthesia.
Exemptions include:
- Services by salaried physicians in government/private training hospitals with pooling.
- Procedures by GPs in PhilHealth-designated shortage areas.
In exemptions, PF computation follows rules specified in prior sections.