Law Summary
Surgeon’s Fee and Services Included
- The peso equivalent per RVU is fixed at 40 pesos.
- Surgeons receive a maximum payment capped at 16,000 pesos for procedures with RVUs above 400.
- Compensation follows a single period of confinement or availment rule.
- Multiple procedures in one session or incision by one or more physicians are compensated using the highest RVU only.
- Surgeries on different dates are compensated according to their respective RVUs but must not exceed total benefit caps.
- PhilHealth’s surgical package covers preoperative, intraoperative, and postoperative services by the operating surgeon.
- Included services comprise:
- Preoperative visits.
- Intraoperative routine care.
- Postoperative care within 90 days and related follow-up visits.
- Specific postoperative interventions such as dressing, incision care, removal of sutures and drains, catheter management, and other routine care.
- Separate fees may apply for co-management if specialist intervention beyond the surgeon’s expertise is required.
Anesthesiologist’s Fee
- The anesthesiologist’s professional fee is 30% of the surgeon’s fee.
- The maximum anesthesiology fee is capped at 5,000 pesos.
- This fee includes postsurgical pain management services.
Operating Room Fee Structure
- Operating room fees are categorized by RVU ranges and hospital classification:
- RVU 30 and below: PH 385 (Primary), PH 670 (Secondary), PH 1,060 (Tertiary)
- RVU 31 to 80: PH 1,140 (Secondary), PH 1,350 (Tertiary)
- RVU 81 and above: PH 2,160 (Secondary), PH 3,490 (Tertiary)
Case Typing and Classification
- Surgical case types based on RVU values:
- Ordinary Cases: RVU 80 and below
- Intensive Cases: RVU 81 to 200
- Catastrophic Cases: RVU above 201
- For multiple surgeries, the case type is based on the highest RVU procedure.
- When case types of surgical procedures and medical diagnoses differ, the higher case type applies.
- Procedures with RVUs 30 and below may be performed outpatient if done in emergency rooms or accredited operating room complexes.
Additional Provisions
- The professional fee includes preoperative, intraoperative, and postoperative care.
- The fixed Peso Conversion Factor (PCF) per RVU is Forty (40.00) pesos.
- Access to the full RVS 2001 manual is through PhilHealth Central and Regional offices or via download from the official website.
This comprehensive framework ensures standardized, fair, and accountable payments for surgical procedures under the Philippine Health Insurance Corporation, with clear guidelines on documentation, fees, classifications, and eligibility criteria.