ALL CASE RATES. ALL CASE RATES POLICY NO. 1 Governing Policies in the Shift of Provider Payment Mechanism From Fee-For-Service to Case-Based Payment.

ALL CASE RATES

ALL CASE RATES POLICY NO. 1

Governing Policies in the Shift of Provider Payment Mechanism From Fee-For-Service to Case-Based Payment

BASES IN THE R.A. 7875

“Equity ““Effectiveness”“Cost Sharing ““Cost Containment”

“Universality”

WHY REPLACE FEE FOR SERVICE

• Inefficient• Overutilization of diagnostic procedures• Unnecessary health care services• Wasteful payments• Inequity when comparing payments to private

and government health care institutions

And because...

COUNTRIES WORLDWIDE HAVE BEGUN TO SHIFT TO

CASE-BASED PAYMENT

SOURCE: “Case-Based Hospital Payment Systems: A Step by Step Guide for Design and Implementation in Low and Middle Income Countries” –

Cashin, et. al, USAID from the American People, December 2005

General Objectives

• To phase out fee-for-service payment mechanism

• To simplify reimbursement rates understood by all sectors

• To improve turnaround time of processing of claims

Scope and Coverage

• 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.

• It shall also apply to all identified day surgeries and select procedures done in accredited health care institutions.

• It shall also be applied to directly filed claims by members subject to compliance to rules on direct filing.

The Fee-for-Service (FFS) system shall be replaced by CASE-BASED payment.

WHAT WILL THE CIRCULAR CHANGE?

FFS 23 Case Rates All Case Rates

WHAT WILL BE THE EFFECTS?

PhilHealth members shall have a much reduced out-of-pocket spending as compared to non-PhilHealth members IF Case Rate (CR) reimbursements is NOT construed as an add-on

All CR payments shall be paid to the account of the HCI.

HCI to pay health care professionals (HCP) not exceeding 30 calendar days

Credentialing and Privileging of doctors shall be delegated to the HCI

HCI shall withhold the expanded withholding tax, VAT, as per BIR policy

WHAT WILL BE THE EFFECTS?

PhilHealth shall NO longer have tiered payments according to training or specialization of the doctors.

Direct filing by members shall only be allowed under certain circumstances.

NBB policy shall apply to ALL CASES, no longer confined to the initial 23.

Post Audit Monitoring is Institutionalized- replacing Pre-Audited Claims Processing

HOW WERE THE RATES DETERMINED?

Methodology

COSTING• using 2 sets of codes:

• ICD 10 for medical conditions• RVS for procedures

GROUPING• condition of similar nature and management were grouped together

AVPC of all ICD

10 codes

+ 20% of the AVPC

Comparison with existing case rates, PF study, actual

rates in database

Condition Case Rates

• Why AVPC?• Source of available data is PHIC dbase• No fair costing studies on PF and hospital charges

Methodology

Procedure Case Rates

Professional Fee: RVU-based rates= RVU x 56 x1.5

• Why RVU?• To make PF rate Commensurate to the level expertise of doctors and receive

what they used to get from PHIC

Facility Fee:Average

hospital fee per RVU +20%

Methodology

1. Conditions of similar nature and management were grouped together

2. Review of grouping and ratesObjective: to validate the ICD codes within the group and rates of the group; to

determine if effect of proposed policies to the grouping and vice versa;

3. Specialty societies were asked to submit a list of their most commonly claimed conditions and procedures

4. Comparison of IPT proposed rates with rates from specialty societies

5. Consultation with societies to verify/validate groups and identify admissions criteria

6. Adjust groups and rates based on consultation7. Actuarial evaluation and projection on proposed case rates

Methodology

We, the (Name of Society), support the Philippine government thru the Department of Health (DOH) and the Philippine Health Insurance Corporation (PhilHealth) in the pursuit of Universal Health Care (UHC) known as Kalusugan Pangkalahatan (KP).

We understand that the achievement of KP is premised on an improved way of provider engagement through a more transparent and efficient provider payment mechanism that is the case rates payment scheme.

We understand that case rates promote equity and financial risk protection especially through the implementation of the No Balance Billing (NBB) Policy for the poor under the Sponsored Program.

In support of KP, we, the (Name of Society) support the implementation of case rates.

Support to Universal Health Care

Consultations with Specialty Societies, Professional Groups, Hospitals, Non-Government Organizations and Other Experts

Includes PMA, PCP, PCS, PPS, PAFP, POGS, PCR, DOH-retained hospitals

Presentation of the All Case Rates Message, Sample Groups and RatesDiscussion of issues on payment of professional fees, credentialing and

privileging and quality care

23 medical specialty societies signed the Support to Universal Health Care (UHC) document including the major societies

– PMA, PCP, PCS, PPS, PAFP, PSA

General Policies1. The FFS is being phased out and the preferred mode

shall be case rates. All claims for medical conditions and procedures submitted to PhilHealth shall be paid using case rates.

All ICD and RVS codes will be given rates2. The objective is to reduce the out-of-pocket

expenditures of patient-members. In no instance, therefore, shall case rates be added to the expenses.

CR payment not an add-on to hospitalization and PF fees

General Policies3. For certain surgical procedures, in order to promote

better efficiency and the most modern interventions, patient admission may not be necessary in the provision of complete quality care. Thus, these surgical case rates shall be paid in full whether done as inpatient or outpatient (i.e., day surgeries). A list of these procedures shall be specified in the implementing guidelines.

General Policies4. All Case Rate Reimbursement will be paid to HCIs.

HCI shall be accountable to PHIC for all that happens to the patient while under their care

HCI to facilitate the payment to health care professionals (HCP) not exceeding 30 calendar days upon receipt of the reimbursement or to a time frame as agreed upon by the specific facility management and their professionals. – PhilHealth shall regularly inform the HCPs of payments made to

the HCI through a furnished copy of the Notice of Paid Claims and/ or Notice of Denied Claims (through email)

HCI as the withholding tax agent for PF fees– withhold the expanded withholding tax and the final value

added tax (VAT) on Government Money Payment (GMP), if applicable

PhilHealth shall withhold the income tax as per BIR policy against the case rate amount to be paid to the HCI

General Policies5. Credentialing and privileging of doctors (including

specialists), and other health care professionals shall be delegated to the concerned HCI. Hospitals will deduct PHIC benefit for eligible patients and file the claims within 60 days except for direct claims No more tiered payments according to training or specialization of

the doctors

6. HCIs shall be responsible to file the claims of PhilHealth beneficiaries within the prescribed period of filing (60 days).

7. Direct filing by members shall only be allowed for certain circumstances as prescribed by PhilHealth.

General Policies8. The No Balance Billing (NBB) policy shall apply to all

indigents and sponsored sectors.9. The Corporation shall set specific case rate

guidelines for the following special circumstances: Geographically Isolated and Disadvantaged Areas (GIDA) Health Human Resource Shortage areas Emergency/ acute care - selected emergency

department visits that are skilfully evaluated and efficiently managed without need for further admission

Other special circumstances as determined by the Corporation

ACR POLICY NO. 2Implementing Guidelines on Medical and Procedure Case Rates

IV. General Rules

A. The case rates shall be the only reimbursement rates for all specified cases. These rates shall be the amount to be paid to the health care institutions and shall include the professional fees (PF). Medical conditions and procedures that are not in the list shall no longer be reimbursed

B. Admission due to patient’s choice shall NOT be reimbursed by the Corporation

IV. General Rules

C. Case rate payments shall cover for– Professional fees– HCI charges, including but not limited to:

• room and board• diagnostics and laboratories• drugs/medicines• supplies• operating room fees• other fees and charges

– Pre-operative diagnostics done prior to confinement are not covered.

IV. General Rules

D. Computation of Reimbursement E. Professional FeesF. Health Care InstitutionsG. Single Period of ConfinementH. Forty-Five Days Benefit LimitI. Special Reimbursement RulesJ. Additional Conditions for EntitlementK. Computation of TaxesL. Quality Standards

IV. D. Computation of Reimbursement

1. For MEDICAL case rates, the HCI fee and the PF shall be 70% and 30% of the case rate amount respectively


2. For procedure case rates, the following shall be the basis for computation except for specified cases: PF = RVU x 56 x 1.5 (except for specified procedure

case rates) HCI fee = case rate amount - PF


3. A list of the complete benefit schedule for medical and procedure case rates (including the exemptions) is provided in Annexes 1 and 2, and shall be posted in the PhilHealth website (www.philhealth.gov.ph).


4. When a patient has multiple conditions that are actively being managed during one confinement, the health care provider may claim for two case rates relevant to the conditions of the patient.


4. When a patient has multiple conditions … The first case rate medical condition or

procedure that used the most resources (drugs and medicines, laboratories and diagnostics, professional fees, etc) in managing the patient

The second case rate medical condition, or procedure with the second most resources used


4. When a patient has multiple conditions … A case rate group shall not be allowed to be used

both as first and second case rate in one claim except for procedures with laterality. Rules on procedures with laterality are found on item IV. G. 4.


4. When a patient has multiple conditions … Initially, NOT all medical conditions or procedures

may be claimed as second case rate. A list of medical conditions, and procedures

allowed as second case rate is provided in Annex 3.

Medical conditions and procedures not included in Annex 3 shall not be reimbursed as second case rate.


5. For a claim with a combination of case rates, the provider shall be paid the full case rate amount for the first case rate plus 50% of the second case rate.

Combination: – medical condition and medical condition; – medical condition and procedure; or– procedure and procedure

HCI Fee (70% of Case Rate)

MEDICAL CASE RATES

If claimed as 1st Case Rate (100% of Case Rate)

Professional Fee (30% of Case Rate)



If claimed as 2nd Case Rate (50% of Case Rate)

HCI Fee (fixed depending on

RVU)

PROCEDURE CASE RATES

If claimed as 1st Case Rate (100% of Case Rate)

Professional Fee (RVU x 56 x 1.5)



If claimed as 2nd Case Rate (50% of Case Rate)

Matrix of Payment for Combination of Case Rates

1st Case Rate (Medical):

Subarachnoid haemorrhage from

middle cerebral artery(ICD 10 Code: I60.1)(Case rate: 100% of

P 38,000 = P 38,000)

2nd Case Rate (Medical): Acute subendocardial

myocardial infarction(ICD 10 Code: I21.4)(Case Rate: 50% of 18,900 = P 9,450)

Hospital Fee(70% of

P 38,000 = P 26,600)

Professional Fee

(30% of P 38,000 = P 11,400)

Hospital Fee(20% of

P 18,900 = P 3,780)

Professional Fee

(30% of P18,900 =

P 5,670)

Total Benefit = P 47,450

Total Hospital Fee = P 30,380

Total Professional

Fee = P 17,070

SAM

PLE

CLAI

M 1


6. List of exemptions to the 50% rule on second case rate, which shall be paid in full even as second case rate:

Table 1. List of Exemptions to the 50% Rule on Second Case Rate

1st Case Rate (Medical): CAP III

(ICD 10 Code: J18.92)

(Case rate: 100% of P 15,000 =

P 15,000)

2nd Case Rate (Procedure): Hemodialysis

(RVS Code: 90935)(Case Rate: 100% of 4,000 = P 4,000)

Hospital Fee(70% of

P15,000 = P 10,500)

Professional Fee

(30% of P 15,000 =

P 4,500)

Hospital Fee(Fixed P 3,500)

Professional Fee

(Fixed P 500 = P 500)

Total Benefit = P 19,000

Total Hospital Fee = P 14,000

Total Professional

Fee = P 5,000

SAM

PLE

CLAI

M 4


7. Aside from being exempted from the 50% rule, claims of multiple sessions of the following procedures under Procedure List A shall be reimbursed even if claimed as second case rate subject to other reimbursement rules.

Table 2. Procedure List AProcedure RVS Code

1 Blood transfusion, outpatient

36430

2 Brachytherapy 77761

77776

77781

777893 Chemotherapy 964084 Dialysis other than

hemodialysis90945

5 Hemodialysis 909356 Radiotherapy 774017 Simple Debridement 11000

11010

11011

11012

11040

11041

11042

11043

11044

11720

11721

16010

21627


8. Computation of reimbursements based on first & second CR (if applicable) as declared by the HCI in PhilHealth CF 2. The total benefit (sum of the first CR and 50% of the second CR) shall be deducted from the total actual charges (HCI fee + PF). The remaining amount shall be charged as out of pocket to the beneficiary except in cases where the NBB policy applies.

Table 2. Computation of Reimbursement and Multiple Sessions in One Claim

XYZ Medical Center – Patient BDiagnosis: Pneumonia, Moderate Risk; Chronic

Kidney DiseaseFirst Case Rate Pneumonia, Moderate RiskSecond Case Rate Hemodialysis x 2 sessionsHospital Charges 25,345.50Total Professional fees 15,000.00Total Actual Charges 40,345.50PhilHealth ReimbursementFirst Case Rate 15,000.00Second Case Rate 8,000.00Total PhilHealth Deductions 23,000.00Total Remaining Balance 17,345.50

Table 3. Computation of Reimbursement for NBB, Multiple Sessions in One Claim

AAA Provincial Hospital – Patient C Diagnosis: Pneumonia, Moderate Risk; Chronic

Kidney DiseaseFirst Case Rate Pneumonia, Moderate RiskSecond Case Rate Hemodialysis x 2 sessionsHospital Charges 25,345.50Total Professional fees 15,000.00Total Actual Charges 40,345.50PhilHealth ReimbursementFirst Case Rate 15,000.00Second Case Rate 8,000.00Total PhilHealth Deductions 23,000.00Total Remaining Balance 0.00

NBB

IV. E. Professional Fees

1. The entire case rate amount, including the PF, shall be paid directly to the HCI concerned. The HCI shall act as the withholding tax agent for the PF.


2. The PF shall be distributed by the HCI within 30 calendar days from the date of receipt of reimbursement. Policies and procedures on the distribution of PF shall be drafted and enforced by the HCI based on the agreements between the HCI and the professionals.


2. ...Reports of noncompliance to this provision shall be forwarded to the PRO Health Care Delivery Management Division (HCDMD) and shall be included as a violation of the HCI to the Health Care Provider Performance Commitment.


3. The government HCI shall facilitate the payment of the pooled PF share to the health personnel. The payment of the pooled PF shall be subject to existing rules on pooling by the Department of Health (DOH).


4. The claims shall still be reimbursed even if managed by several doctors (accredited and non-accredited) provided the said case is attended by at least one (1) PhilHealth accredited doctor.


5. The HCIs shall inform the concerned professionals of the status of their claim whether the claim was paid, returned to sender (RTS) or denied.


6. To facilitate distribution of the PF within the prescribed/agreed schedule, each printed voucher for reimbursed HCI claims corresponding Claims Summary Report. Claims Summary Report contains all information in the voucher + the name/s of doctor/s who attended to the patient. This shall be sent to the hospital along with the voucher.

IV. F. Health Care InstitutionsTable 3. List of Procedures and Medical Conditions Allowed in Different Types of Health Care Institutions

IV. F. Health Care Institutions

2. Primary Care Facilities – Infirmaries/Dispensaries Claims of PCF shall be limited to the medical

conditions and procedures enumerated in PC 14 s. 2013 and its amendments. The complete list is in Annex 5 and 6.


2. Primary Care Facilities – Infirmaries/Dispensaries Primary care facilities shall be reimbursed at 70%

of the case rate except for the following case rates enumerated in PC 14, s 2013,which are hereby assigned new classifications:


• Reimbursement for these medical case rates shall be maintained at 100% of case rates until December 31, 2013 after which, the 70% rate shall be implemented

2. Primary Care Facilities – Infirmaries/Dispensaries

2.c. The HCI fee shall be 70% of the HCI fee for hospitals. Likewise, the PF shall also be 70% of the PF allotted for hospitals. To illustrate:


2.d. The following procedures shall be reimbursed at 100% of case rate when done in accredited PCF :



2. Primary Care Facilities – Infirmaries/Dispensaries

3. Claims for medical and procedure case rates that are beyond the service capability of the HCI shall be denied.

Single Period of Confinement

PC 35 s 2013 Item IV.G

1. Admissions and readmissions due to the same illness or procedure within a 90-calendar day period shall only be compensated with one (1) case rate benefit.

First and second case ratesboth evaluated for compliance with the SPC rule

Table 4. List of Case Rates Exempted from the SPC Rule

Table 4. Single Period of ConfinementFirst Admission Second Admission

Case A

1st Case Rate2nd Case Rate

Decision

January 1 - 7, 2014

Pneumonia, HRHemodialysis

Both case rates are paid in full. HD is exempted from 50% rule for 2nd case rate.

March 1- 4, 2014(59 days from previous confinement)AppendectomyHemodialysis

Both case rates are paid in full. HD is exempted from SPC.

Table 4. cont’nFirst Admission Second Admission

Case B


Decision

January 1-9, 2014

Stroke - InfarctionIHD with MI

Stroke - infarction paid in full. IHD with MI paid at 50% of case rate.

March 21-26, 2014(79 days from previous confinement)Pneumonia, HRIHD with MI

Pneumonia is paid in full. IHD with MI is denied; covered by SPC.



4. Identified procedures, when done on the contralateral side, shall also be exempted from the SPC rule (Annex 7).The health care provider shall always indicate the laterality of these procedures in the claim form.



4. …When the identified procedures are done on both sides during one confinement, the second procedure shall be considered as the second case rate and shall be reimbursed at 50% of the case rate.



4. …Except for cataract package surgeries (RVS 66983, 66984 and 66987), which are subject to the provisions in PC 17 s. 2013These procedures with laterality may not be claimed as second case rate together with other medical conditions/procedures.

Table 5

45 Days

PC 35 s 2013 Item IV.H

2. The total number of confinement days shall be deducted from the 45-day benefit limit of the beneficiary except for the following medical/procedure case rates with pre-determined number of days deduction.

45 days confinement for members, and 45 days for dependents per calendar year

45 Days


Six days of dialysis, regardless of the number of exchanges per day, shall be equivalent to one day deduction from the 45 days allowable benefit per year.

If procedure is done during a confinement, whether in the same HCI or not, only the total number of confinement days shall be deducted from the 45 days total allowable benefit for the beneficiary.

Dialysis other than hemodialysis e.g., peritoneal dialysis (RVS 90945)

Table 6.1 Forty-Five Days Benefit Limit – Peritoneal Dialysis

Patient A Patient BHospitalAdmission DateDischarge DateTotal # Days

XYZ Medical CenterFebruary 8February 2618 days (OPD)

ABC HospitalFebruary 15February 183 days


Peritoneal dialysis (PD) (18 days)

AGE, moderate dehydrationPeritoneal dialysis (4 days)

Total deduction from 45 days benefit limit

3 days (Every 6 days of PD is equivalent to one day deduction. 18 days of PD is equivalent to 3 days deduction.)

3 days (Only the number of days of confinement is deducted from the benefit limit. The PD is not added to the deduction.)

45 Days


One cycle of chemotherapy is equivalent to two (2) days deduction from the 45 days allowable benefit per year regardless of the number of days of confinement per cycle.

If procedure is done during a confinement, whether in the same HCI or not, only the total number of confinement days shall be deducted from the 45 days total allowable benefit for the beneficiary

Chemotherapy (RVS 96408)

Table 6.2 Forty-Five Days Benefit Limit – Chemotherapy

Patient CHospitalAdmission DateDischarge DateTotal # Days

NOP HospitalJanuary 9January 134 days

DiagnosisProcedures

Colon CancerChemotherapy x 1 cycle


4 days (Only the number of days of confinement is deducted from the benefit limit. The chemotherapy is not added to the deduction.)

45 Days


One session for each procedure is equivalent to one day deduction from the 45 days allowable benefit per year.

Blood Transfusion, Outpatient (RVS 36430)

45 Days


One session for each procedure above is equivalent to one day deduction from the 45 days allowable benefit per year.

If procedure is done during a confinement, whether in the same HCI or not, only the total number of confinement days shall be deducted from the 45 days total allowable benefit for the beneficiary.

Radiotherapy (RVS 77401) and Hemodialyis (RVS 90935)

Table 6.3 Forty-Five Days Benefit Limit

Patient D Patient EHospitalAdmission DateDischarge Date# Days Confined

XYZ Medical CenterJanuary 10January 188 days

NOP HospitalJanuary 10January 188 days

DiagnosisProcedures

Breast CancerRadiotherapy x 1 session (sent to ABC Hospital*)

Breast CancerRadiotherapy x 1 session (done in-hospital)


8 days (claim 1 - 8 confinement days + claim 2*- 0 day deduction for the radiotherapy since procedure is done while patient is confined)*ABC Hospital files separate claim for the radiotherapy session.

8 days (Only the number of days of confinement is deducted from the benefit limit. The radiotherapy session is not added to the deduction.)

45 Days


3. For claims with combination of case rates, the single period of confinement rule shall be applied prior to evaluation of deductions from the 45 days benefit limit. In cases when one of the two case rates claimed is denied due to the single period of confinement rule, then the rule for the approved case rate is used to determine the number of days to be deducted from the 45 days benefit limit.

Table 7.1 Forty-Five Days Benefit Limit and Combination of Case Rates

Patient A First Admission Second AdmissionAdmission DateDischarge DateTotal # Days1st Case Rate2nd Case Rate

January 1, 2014January 9, 20148 daysStroke - InfarctionIHD with MI

March 21, 2014 March 26, 20145 daysPneumonia, HRIHD with MI

Decision


Pay 1st case rate in full and 2nd case rate 50%8 days (assuming no benefit availments within previous 90 days)

Pay 1st case rate in full. Deny 2nd case rate (covered by SPC).5 days

Remaining Benefit 37 days (45 – 8 days) 32 days (37 – 5 days)

Table 7.2 Forty-Five Days Benefit Limit and Combination of Case Rates

Patient B First Admission Second AdmissionAdmission DateDischarge DateTotal # Days1st Case Rate2nd Case Rate

January 1, 2014January 10, 20149 daysStroke - InfarctionIHD with MI

March 21, 2014 March 26, 20145 daysIHD with MIHemodialysis x 2 sessions

Decision


Pay 1st case rate in full and 2nd case rate 50%

9 days (assuming no benefit availments within previous 90 days)

Deny 1st case rate (covered by SPC). Pay 2nd case rate in full (HD exempted from 50% rule for 2nd case rate).

2 days (Use only # sessions of HD since 1st case rate is denied. 1 session of HD is equivalent to 1 day deduction)

Remaining Benefit 36 days (45 – 9 days) 34 days (36 – 2 days)

I. SPECIAL REIMBURSEMENT RULES

1. Referral Package (P00001)

• Reimbursement of the full case rate package shall be paid to the referral (receiving) hospital.

• Claims filed by the referring hospital shall be reimbursed a fixed amount of 4,000 pesos

• The HCI fee and PF shall be 70% and 30% respectively

PC 35 s 2013 Item IV.I


• Claims for referrals shall only be allowed if the transfer is to a higher level hospital except in Level 3 hospitals where transfer to the same level is allowed: Level 1 to Level 2, Level 1 to Level 3, Level 2 to Level 3 or Level 3 to Level 3


Claims for referrals shall be

limited to the conditions listed

in ANNEX 8!


• Claims for referrals shall be filed following the same rules as a regular case rate as contained in this circular.

• Special requirementsThe referring and referral hospital shall indicate the

complete admission and final diagnoses in their respective claim forms.

The referring hospital shall indicate the referral package code in the first case rate field in Claim Form 2.

The referral hospital indicates the appropriate case rate codes in the first and second (if applicable) case rate field/s in Claim Form 2.


The referring and referral hospitals

must tick the appropriate box

provided in Claim Form 2 in order for

them to get reimbursement.


A duly accomplished referral form

(Annex 9) is also required for

reimbursement.



• In cases of series of referrals, Only the first and last hospitals to handle the

patient shall be reimbursed. oClaims of the facilities in between shall be denied.


Hosp A CB D


• Claims for referral from accredited Maternity Care Package (MCP) shall still be reimbursed based existing rules

– Other claims for referral package from the following HCI shall be denied:

»Freestanding Dialysis Center»Ambulatory Surgical Clinic»Rural Health Units/Health Center »Primary Care Facilities


2. Confinement Abroad

• For confinements abroad, the claim shall be reimbursed the full case rate amount based on the final diagnosis/es.

• Requirements for filing of claims Claim form 1 Statement of account Certification from the physician English translations


3. Direct Payment to Member

• Full case rate payment shall be directly paid to the member

• Direct filing of claims shall not be allowed except in the following cases:

1. Claims for confinements abroad2. Emergency in non-accredited HCIs


4. Overlapping Claims

• Overlapping of claims happens when two or more claims of one beneficiary have the same or intersecting confinement periods.

• In cases of overlapping claims, both (or all) claims shall be evaluated and validated.

• Only the valid claim/s shall be reimbursed following rules on reimbursement. Invalid claims Legal Services Unit of the PRO


5. Others

• If the patient dies… and a procedure has been done case rate of the

procedure as claimed by the HCI following the rules contained in this circular.

but was confined for more than 24 hours case rate as claimed by the HCI following the rules.


5. Others


• Immediate cause of death (disease, injury, or complication that caused death) shall be the basis for the case rate/s that will be claimed. This does not mean the mode of dying, e.g., Cardio-Respiratory Arrest.

• If a procedure has been done, the procedure and/or the immediate cause of death may be claimed as first and/or second case rate. The rule on first and second case rate applies.

J. ADDITIONAL CONDITIONS FOR ENTITLEMENT

Change in Accreditation of HCI

• In case of change in STATUS, the claim shall still be paid the full amount of the case rate as long as one day of the confinement falls within the validity of the accreditation of the HCI.

• In case of UPGRADE, the claim shall be reimbursed based on the category at the date of discharge.

• In case of DOWNGRADE the claim shall be reimbursed based on the category at the date of admission

PC 35 s 2013 Item IV.J

Membership and Dependency

• As long as one day of the confinement falls within the validity of either membership or dependency, the beneficiary is entitled to the full PhilHealth benefit.


Out-on-pass

• Except for day surgeries and Millennium Development Goal (MDG) packages, as long as the beneficiary is admitted for at least 24 hours, the beneficiary is entitled to the full PhilHealth benefit subject to other rules of reimbursement.


Non-availability of room This refers to cases when admitted patients must stay in the

emergency room or within the hospital premises pending the availability of rooms. Day surgeries and MDG packages are exempted from this rule.

Full payment shall be given if the patient stayed in the hospital for 24 hours or more. However, private HCIs shall submit a letter of justification with the claim. Non-submission of requirements shall result in the denial of the claim.

If the patient stayed in the HCI for less than 24 hours, the claim shall be denied


K. Computation of Taxes

PhilHealth adheres to the prescribed computation of taxes issued by the Bureau of Internal Revenue

L. Quality Standards

• Clinical Practice Guidelines (CPG) adopted by societies, the Department of Health (DOH) or as provided by the World Health Organization (WHO) or if not available,

• Current accepted standards of care, to support their diagnosis and management.

• Claims filed shall be subject to post-audit evaluation to check for the quality of care provided to the patient-beneficiary

• Upon evaluation and monitoring, all inconsistencies regarding reimbursement policies shall be charged to future claims of the facilities.

MEDICAL CASE RATES

The complete list of reimbursable medical case rates, including the specific ICD 10 codes and rates is found in Annex 1 (www. Philhealth.gov.ph)

• Only admissible medical conditions shall be reimbursed by PhilHealth

• For medical conditions that are managed primarily using interventional or surgical procedures, health care providers shall use the appropriate procedure case rates.

• Specific diagnostic/laboratory examinations shall no longer be prescribed for all medical case rates.

MEDICAL CASE RATES

1. AGE and non-hepatic amoebiasis• E86.1 – moderate/marked dehydration• E86.2 – severe dehydration

2. Asthma in acute exacerbation• Additional 5th character ICD 10 code

3. Maternal co-morbidities conditions• Admission that do not lead to delivery• If the co-morbidity has no case rate available from the list

4. Pneumonia• Additional 4th or 5th character ICD 10 code

MEDICAL CASE RATES


The complete list of reimbursable procedure case rates is found in Annex 2 (www. Philhealth.gov.ph).

1. Adhesiolysis (RVS 44005) shall only be reimbursed if performed independent of any other procedure.

2. Blood transfusion, outpatient (RVS 36430) • This package covers outpatient blood transfusion only.

Inpatient transfusion of blood or blood products shall be covered by the medical case rate of the patient.

• One day of transfusion of any blood or blood product, regardless of the number of bags, is equivalent to one session.

• Multiple sessions may be claimed in one claim form. The dates of each session claimed shall be indicated in the blank provided in Claim Form 2.


3. Cataract Package (RVS 66983, 66984 and 66987)– Cataract extraction and vitrectomy. For claims of cataract

extraction that are accompanied by vitrectomy secondary to posterior capsular rupture resulting from cataract surgery, only the cataract extraction shall be paid. Moreover, a claim for postoperative vitrectomy performed within 90 days from cataract surgery shall be denied reimbursement whether done during the same or different confinement.

– Vitrectomy performed at the time of cataract extraction shall only be paid if an indication specified in the admitting diagnosis supports the performance of the procedure. In such case, payment of professional fee and hospital charges shall be based on vitrectomy and not on the cataract surgery.


4. Cesarean section (CS) (RVS 59513, 59514, 59620). Cesarean section per patient request shall not be reimbursed by the Corporation.

5. Chemotherapy (RVS 96408)• The case rate amount for chemotherapy is equivalent to one

cycle of chemotherapy.• One cycle of chemotherapy is equivalent to 2 days deduction

from the 45 days benefit allowance.• Chemotherapy may be claimed as inpatient or outpatient.

– If claimed as inpatient and in the same HCI, this package may be claimed as first or second case rate.

– Multiple cycles may be claimed in one claim form for both inpatient and outpatient chemotherapy. The dates of each cycle claimed shall be indicated in the space provided in Claim Form 2.


6. Circumcision (RVS 54150, 54152, 54160, 54161). Circumcision shall only be reimbursed if done secondary to phimosis (ICD 10: N47).

7. Dialysis other than hemodialysis (e.g., peritoneal dialysis) (RVS 90945)• The case rate amount for Dialysis other than hemodialysis (e.g.,

peritoneal dialysis) is equivalent to 6 days of PD exchanges.• All PD exchanges done for six days shall be charged one day

against the 45-day benefit allowance. Claims of less than 6 days of exchanges shall also be charged one day against the 45-day benefit allowance.

• Multiple sessions may be claimed in one claim form. The dates of each session claimed shall be indicated in the blank provided in Claim Form 2.


8. Hemodialysis (RVS 90935) • This package covers BOTH inpatient and outpatient hemodialysis

procedures including emergency dialysis procedures for acute renal failure.

• Reimbursement shall include payment for use of the dialysis machine and health care institution, drugs and medicines, supplies and others on per session basis.

• Creation of fistula shall be reimbursed using a different case rate but in accredited health care institutions only.

• Multiple sessions may be claimed in one claim form for both inpatient and outpatient hemodialysis. The dates of each session claimed shall be indicated in the space provided in Claim Form 2.

• If an admitted patient is sent to another HCI for hemodialysis, a separate claim shall be filed by the HCI that performed the dialysis. This shall be reimbursed the full case rate.


9. Radiation therapy (RVS 77401)• This includes radiation treatment delivery using cobalt and linear

accelerator. The HCI shall indicate in Claim Form 2 which between cobalt and linear accelerator was done.

• Multiple sessions may be claimed in one claim form for both inpatient and outpatient radiation therapy. The dates of each session claimed shall be indicated in Claim Form 2.

• If an admitted patient is sent to another HCI for radiation therapy, a separate claim shall be filed by the HCI that did the radiation therapy. This shall be reimbursed the full case rate.

• Radiotherapy performed on the same day as brachytherapy (RVS 77761, 77776, 77781 and 77789) or chemotherapy (RVS 96408) shall be reimbursed the full case rate subject to other reimbursement rules. The equivalent deductions shall be made to the 45 days benefit limit of the beneficiary.


10. Vaginal delivery (RVS 59409). This includes deliveries done vaginally for mothers with medical conditions or other indications that exempt them from the normal spontaneous delivery package. • The following are the accepted indications:

– Preterm deliveries O60.1– Multiple deliveries O84.0– Maternal distress during delivery (unstable vital signs) O75.0– Delayed delivery after rupture of membranes O75.6– Abnormality in uterine contraction O62.4– Prolonged labor O63.-– Precipitous delivery O62.3– Labor complicated by fetal distress O68.-– Labor complicated by cord complication O69.-


MILLENNIUM DEVELOPMENT GOAL PACKAGES

• The following packages shall be paid using case-based payment but will follow the existing rules of reimbursement, payment and claims filing contained in their respective circulars.

1. Maternity Care Package (RVS 59401) 2. Outpatient HIV/AIDS Treatment Package (RVS 99246)3. Animal Bite Package (RVS 90375)4. Outpatient Malaria Package (RVS 87207)5. TB-DOTS (RVS 89221, 89222)6. Newborn Care Package (RVS 99432)

Z benefit packages

• Excluded from the all case rates policy and shall be governed by existing circulars.

X. FILLING OUT THE CLAIM FORMS

• The PhilHealth claim forms must be properly and completely filled out, otherwise, it shall be returned to sender (RTS)

• The PhilHealth accredited healthcare provider shall also write the complete admitting and final diagnoses in the claim form

• Incorrect/incomplete/without, ICD 10 or RVS codes shall be RTS.

• Claims with discharge diagnoses written in Claim Form 2 as ill-defined and/or suspected diagnoses i.e., • “to consider (T/C)”, • “versus or vs.”, • “rule out (R/O)”, • “probable”, or • “potential”

shall be denied

• The Corporation shall only allow (RTS) with admission dates on or before March 31, 2014.

• RTS shall no longer be allowed for all claims with date of admission starting April 1, 2014.

• Instead, these claims shall be denied.• All claims that were returned to the sender for

correction or completion shall be re-filed within 60 days from receipt of notice

• Re-filed claims with non-compliance to deficiencies stated in RTS shall be denied.

• A properly and completely filled out Claim Form 3 shall be required for MCP claims and cases managed in PCF.

• Records of anesthesia and surgical or operative technique are required for all procedure claims except for some procedures listed in ANNEX 10

NBB

The No Balance Billing Policy shall be applicable to all case rates.

Monitoring and Evaluation/Post Audit of Case Rate Claims

• Providers shall be monitored on their compliance to this circular and violations shall be dealt with in accordance with the provisions of PhilHealth Circular No. 54 s. 2012 (Provider Engagement through Accreditation and Contracting for Health Services) and other pertinent issuances.

• The penalties to these violations shall be charged to future claims of the health care institution or as determined by the Corporation.

EFFECTIVITY

15 days after publication

List of AnnexesAnnex 1: List of Medical Case RatesAnnex 2: List of Procedure Case RatesAnnex 3: List of Medical Conditions and Procedures Allowed as Second

Case RateAnnex 4: Examples and Scenarios for the All Case Rates Implementing GuidelinesAnnex 5: List of Medical Case Rates for Primary Care Facilities- Infirmaries/DispensariesAnnex 6: List of Procedure Case Rates for Primary Care Facilities – Infirmaries/DispensariesAnnex 7: List of Procedures with LateralityAnnex 8: List of Medical Conditions Allowed for Referral PackageAnnex 9: Referral FormAnnex 10: List of Alternative Documents for Record of Operative or Surgical TechniqueAnnex 11: PhilHealth Claim Forms 1, 2 and 3

FROM FEE-FOR-SERVICE… TO CASE-BASED PAYMENT

FROM CHAOS… TO ORDER

THANK YOU FOR LISTENING

For comments, suggestions, questions: Email us at

[email protected]