Title
No Balance Billing Policy Enforcement
Law
Philhealth Circular No. 0003, S. 2014
Decision Date
Jan 9, 2014
PhilHealth Circular No. 0003, issued on January 9, 2014, reinforces the No Balance Billing (NBB) policy to ensure that indigent patients receive comprehensive healthcare without incurring additional costs beyond the packaged rates, mandating healthcare institutions to provide quality care and necessary services without extra charges.
no balance
billing
philhealth policy

Legal basis and governing framework

  • Section 43 of the Implementing Rules and Regulations of Republic Act No. 10606 (National Health Insurance Act of 2013) requires that no other fee or expense shall be charged to the indigent patient, subject to guidelines issued by the Corporation.
  • The Circular is implemented within the National Health Insurance Program (NHIP) framework under Republic Act No. 10606.
  • Penalties for violations are enforced under RA 7875, as amended, and its Implementing Rules and Regulations, consistent with the signed Performance Commitment and related PhilHealth issuances.

Policy intent and enforcement focus

  • The Circular strengthens enforcement of the NBB policy that prevents charging or paying any other fees or expenses above and beyond the packaged rates for indigent patients.
  • The Circular emphasizes that effective implementation requires strong political will of both national and local government in resource management and policy enforcement to protect poor Filipinos against financial risk.
  • The Circular ties NBB to the case payment system, including the provision of complete quality care to attain the best possible health outcomes.

Defined persons, membership categories, and scope

  • NBB Patients covered include members and dependents in these membership categories:
    • Indigent: a person with no visible means of income or whose income is insufficient for family subsistence, identified by DSWD using criteria under the guiding principles in Article I of Republic Act No. 10606.
    • Sponsored: a member whose contribution is paid by another individual, government agency, or private entity under rules prescribed by PhilHealth.
    • Household Help: as defined in Republic Act No. 10361 (“Kasambahay”).
    • Group Gold: Group Gold members with existing Group Policy Contract (GPC) retain NBB privilege until expiration or until the contract ends; when existing GPCs end, NBB is no longer accorded to the Organized Groups.
  • The Circular covers benefits using case-based payments, including:
    • All Case Rates
    • 23 Case Rates enumerated in PhilHealth Circular No. 11, s-2011
    • Case Type Z benefits
    • Leptospirosis Package
    • TB-DOTS Package
    • Outpatient Malaria Package
    • Animal Bite Treatment Package
    • Voluntary Surgical Contraception Package
    • Other covered benefits:
      • Outpatient HIV/AIDS Treatment (OHAT) Package
      • Severe Acute Respiratory Syndrome (SARS) Package
      • Avian Influenza Package
      • Intrauterine device (IUD) insertion
  • The Circular applies to accredited government health care institutions, including all levels of hospitals and other facilities (e.g., ambulatory surgical clinics, freestanding dialysis clinics, infirmaries, dispensaries, birthing homes, DOTS Centers).
  • The Circular applies to accredited private health care institutions through the covered private facility/benefit rules:
    • Private facilities subject to NBB include contracted facilities for Z Benefit Packages, ambulatory surgical clinics, freestanding dialysis centers, TB DOTS Centers, birthing homes, and infirmaries/dispensaries with limited scope.
  • Private infirmaries and dispensaries: NBB applies only to claims for Maternity Care Packages and Newborn Care Packages; all other benefits are not subject to NBB for private infirmaries/dispensaries.
  • Private facility NBB coverage by facility type includes:
    • Ambulatory Surgical Clinics: NBB applies to all benefits covered by NBB, including cataract extraction, BTL, and vasectomy.
    • Freestanding Dialysis Clinics: NBB applies to the Dialysis Package.
    • TB DOTS Centers: NBB applies to the DOTS Package.
    • Birthing Homes: NBB applies to MCP, NCP, and IUD insertion.
    • Infirmaries/Dispensaries:
      • Government infirmaries: NBB applies to all benefits covered by NBB, including vasectomy.
      • Private infirmaries: NBB applies to MCP and NCP only.

Substantive NBB obligations and patient protections

  • Health care institutions must provide NBB patients preferential access to their social welfare funds, which may augment the benefit package when needed to cover all confinement charges.
  • Institutions are responsible and accountable for patient care and must extend all medical and financial support to qualified NBB members and dependents.
  • Institutions must not deny access to health services when necessary.
  • Health care providers must deliver utmost quality of care and provide complete medical and non-medical care, including drugs, supplies, diagnostics, and adequate patient meals based on prescribed therapeutic diet, nutritional status, and dietary requirements.
  • If the patient requires intensive care unit, isolation room, recovery room, or other special accommodation, the provider must provide it and the NBB policy applies.
  • When qualified NBB members and dependents are admitted in ward type accommodation, they are covered by the NBB policy.
  • When ward type accommodation is not available, the provider must make the next higher accommodation available at no added cost.
  • If the patient opts to avail private accommodation, the NBB policy does not apply to that choice.
  • Hospitals must ensure there is always an available health care professional to manage the patient.
  • The patient must not be charged for professional fees, whether the health professional is salaried or not.
  • Medication, diagnostics, and supplies sourced outside the facility may be used only as a last resort after exhausting other sourcing options.
  • When outside sourcing is used as a last resort, the health care institution must exclusively bear the cost of acquisition of such commodities and services.

Prior verification, portals, and eligibility proof

  • Membership verification must occur prior to hospital admission and prior to the availment of outpatient services to prevent any out-of-pocket expenditures for qualified NBB members and dependents.
  • Government facilities must have the capacity for real-time verification of membership and eligibility.
  • Government facilities must implement the Institutional Health Care Provider Portal (IHCP Portal):
    • The IHCP Portal is an online verification system that requires only a computer with internet connection.
    • PhilHealth ensures the deployment of the IHCP Portal.
    • Government facilities must provide resources for optimal use, including dedicated personnel and a computer with reliable internet access.
  • Indigent members may present Member Data Record (MDR), PhilHealth Number Card (PNC), or PhilHealth Identification Number (PIN) as proof of membership and eligibility upon admission.
  • 4Ps ID cards must be accepted as proof of membership:
    • The hospital accepts Pantawid Pamilyang Pilipino Program (4Ps) ID cards pursuant to PhilHealth Circular 24, s-2012.
    • The mere presentation of the card is treated with presumptive validity and in good faith.
  • If the hospital cannot access the IHCP Portal, the provider must devise a mechanism to verify membership and eligibility prior to admission by coordinating with PhilHealth CARES personnel assigned to the facility or by calling the Local Health Insurance Offices (LHIOs) for verification.

Claims compliance, incentives, monitoring, and complaint mechanisms

  • Quality of care is monitored and evaluated through a Post-audit System, and PhilHealth imposes sanctions based on existing rules for facilities compromising quality of care.
  • No Balance Billing beds must follow the specifications in PhilHealth Circular No. 22, s-2012; nonconformity constitutes breach of Performance Commitment subject to sanctions under the same Circular.
  • Hospitals must ensure availability of medications, diagnostic tests, and supplies through:
    • A hospital Formulary maintained by the Therapeutics Committee in compliance with DOH AO No. 51 of 1998, using the latest edition of the Philippine National Formulary (PNF).
    • Forecasting by the Therapeutics Committee to maintain sufficient supplies based on prevailing morbidity and mortality profiles.
    • Dispensing prescribed medications exclusively from the hospital pharmacy for qualified NBB members and dependents.
  • When medications or alternatives are unavailable, the facility must provide at no cost to the patient through:
    • Consignment: government hospitals may consign, contract, or enter agreements with licensed suppliers to ensure availability.
    • Consignment agreements are discouraged if they involve third parties owned by hospital employees and their immediate relatives to avoid conflict of interest.
    • Prescribing: physicians must ensure prescribed medications and supplies are available in the hospital pharmacy; physicians must prescribe PNF drugs in generics, and brand names must not be indicated.
    • Generic substitutions: health care institutions must strictly observe and impose generic substitutions to meet patient needs within available resources.
  • Diagnostics must be handled by:
    • Performing all necessary laboratory and diagnostic procedures to establish a definitive, accurate diagnosis and achieve the best outcome.
    • When a test is unavailable, arranging referral and endorsement to the nearest government hospital or private diagnostic center at no cost to the patient.
    • For non-ambulatory patients, arranging patient transport via ambulance at no additional cost to qualified NBB members and dependents.
  • Professional services of salaried physicians:
    • Salaried physicians must not charge additional professional fees beyond the professional fees provided by the Program for members admitted to a service bed.
    • Salaried physicians must not charge additional professional fees to qualified NBB members and dependents, premised on pooling of professional fee component for PhilHealth reimbursements within the facility.
  • Professional services of non-salaried physicians (consultants):
    • Consultants must not charge additional professional fees to qualified NBB members and dependents admitted in ward type accommodation.
  • Referral systems:
    • Health care professionals must not resort to unnecessary referrals solely due to lack of resources.
    • When referral is necessary, providers must arrange endorsement, transportation, and accommodation.
  • Hospitals are encouraged to develop NBB packages corresponding to PhilHealth case-rate packages, including accommodation, operating room complex use, professional fees, drugs and medicines including biologicals, supplies, and diagnostic and therapeutic procedures.
  • Incentives and claims processing:
    • PhilHealth facilitates payments to hospitals found to be efficiently implementing NBB.
    • Claims from highly compliant hospitals are paid within 30 days upon receipt of complete documents.
    • If hospitals enter consignment or other agreements necessitating payments to stakeholders outside the government facility, PhilHealth supports by fast tracking claims payment within 30 days from receipt.
  • Information dissemination:
    • Qualified NBB members and dependents must be oriented on PhilHealth’s NBB policy upon admission.
    • Hospitals, with PhilHealth CARES, must orient members and dependents on case rates and NBB policies using IEC materials provided by PhilHealth.
    • Qualified NBB members and dependents must be informed they have a choice to opt for ward type accommodation.
  • Monitoring and evaluation:
    • PhilHealth’s Standards and Monitoring Department regularly monitors facilities’ compliance.
    • An exit interview is conducted randomly by PhilHealth among NBB patients prior to discharge; if a violation is noted, a Case Documentation/Action Form is completed and sent to the PRO-HCDMD Chief.
    • Post-audit is conducted by the PRO-HCDMD for claims where NBB policy applies.
    • If a violation is found, the HCDMD Chief through AQAS and the Legal Services Unit conducts validation by performing a domiciliary visit.
    • Findings are then submitted to the RVP through the HCDMD for appropriate action.
  • Grievance and complaints:
    • Members may report NBB violations to PhilHealth CARES assigned within the facility; CARES includes incidents in the monthly report to the HCDMD Chiefs or FOD as applicable for action.
    • PhilHealth provides an SMS Hotline managed by the PhilHealth Corporate Action Center for reporting NBB violations.
    • SMS reports are validated by PhilHealth Regional Offices through PhilHealth CARES, PhilHealth Anti-Fraud Team, and AQAS.
    • Violations may also be reported to:

Penalties, separability, and compliance consequence

  • For any violation of the Circular, penalties are imposed in accordance with the signed Performance Commitment terms and conditions and all existing related PhilHealth circulars, office orders, and directives.
  • Penalties for violations are enforced under RA 7875, as amended, and its Implementing Rules and Regulations.
  • Separability: If any part or provision is declared void by a court of law or competent authority, the unaffected provisions remain valid and effective.

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