Philhealth bares new method of paying medical care benefits PDF Print E-mail
Monday, 21 November 2011 15:29

Philippine Health Insurance Coporation (PhilHealth) has adopted a new method of paying the medical care benefits of its members through the partners in health care delivery effective September 1, 2011.

This is contained in PhilHealth Circular numbers 11, 11-A & 11-B (Fixed Rate Cases & No Balance Billing Policy).

The Fixed Rate Cases method to pay for selected medical cases and surgical procedures aims to provide optimal financial risk protection especially to the most vulnerable groups, including the poorest of the poor. The Corporation would also want to empower the members more by letting them know exactly how much they can now avail themselves of for certain medical conditions and surgical procedures. Thus, for the partner-providers, the Fixed Rate Cases method equates to faster processing of claims and therefore faster reimbursement for the services they have provided to the members.

Earlier, PhilHealth has used the Fixed Rate Cases for such conditions as the outpatient malaria treatment, HIV/AIDS, tuberculosis treatment, cataract surgery and a lot more. However, this time, PhilHealth has expanded the list to include the most common medical conditions that they pay for, meaning, these comprise about 49 percent of all claims that they received, processed and paid for over the last year.

The following are the Fixed Rate Cases:
Dengue I    P8,000.00
Dengue II    P16,000.00
Pneumonia I    P15,000.00
Pneumonia II    P32,000.00
Essential hypertension    P9,000.00
Cerebral infarction    P28,000.00
Cerebro-vascular accident with hemorrhage    P38,000.00
Acute gastroenteritis    P6,000.00
Asthma    P9,000.00
Typhoid fever    P14,000.00
Newborn care package in hospitals and lying-in clinics    P1,750.00
Radiotherapy    P3,000.00
Hemodialysis    P4,000.00

Maternity Care Package

Normal Spontaneous Delivery Package in Level 1 hospitals

Normal Spontaneous Delivery Package in Levels 2 to 4 hospitals P8,000.00
Caesarean Section    P19,000.00
Appendectomy    P24,000.00
Cholecystectomy    P31,000.00
Dilatation and curettage    P11,000.00
Thyroidectomy    P31,000.00
Herniorrhaphy    P21,000.00
Mastectomy    P22,000.00
Hysterectomy    P30,000.00
Cataract surgery    P16,000.00

These new rates are applicable for all types of members, including those who are employed in the private and government sectors, the lifetime members, the overseas workers, the individually paying members and the sponsored program members. They may avail themselves of these Fixed Rate Cases in PhilHealth-accredited health care facilities nationwide.

However, the Sponsored Program members, are entitled to the ‘No Balance Billing’ policy when they avail themselves of any of these fixed case rates in the accredited government hospitals.

No Balance Billing means that no other fees or expenses shall be charged or paid for by the patient-member above and beyond the packaged rates.

This policy also applies when the Sponsored Program members avail themselves of outpatient surgeries, hemodialysis and radiotherapy in accredited non-hospital facilities that includes Free-Standing Dialysis Centers (FSDCs) and Ambulatory Surgical Clinics (ASCs). It also applies when they are availing themselves of the existing outpatient packages for TB-DOTS, Malaria and HIV/AIDS.

At the same time, all other member-types (employed in the private and government sectors, the lifetime members, the overseas workers, the individually paying members) are entitled to the No Balance Billing policy when availing themselves of the Maternity Care Package (MCP) and the Newborn Care Package (NCP) in accredited non-hospital providers (Rural Health Units, Birthing Homes). — PIA