By PNA and Philippine Times of Southern Nevada
The Philippine Health Insurance Corporation (PhilHealth) will start on September 1 implementing a new payment system on selected medical cases and surgical procedures that would be favorable both to its members and health care providers, a top regional official of the agency for Bicol announced over the weekend.
The new system will be a shift from the fee-for-service to the case rate payment mechanism which is an internationally accepted payment procedure and much simpler to administer, more transparent and would enable members to determine how much the health insurance agency would be paying for each of the services availed of from accredited doctors and hospitals.
The shift was prompted by developments taking place in the health care industry, most notable of which is the need to provide optimal financial risk protection especially to the most vulnerable groups, including the poorest of the poor, according to Dr. Ronald Santelices, the regional chief for Bicol of the PhilHealth’s Benefit Administration Section based here.
He said the new system will result to faster reimbursement of fees to both the health care providers and members. It will be applied to all member-types admitted in any of the PhilHealth-recognized health care services institutions nationwide.
For members under the sponsorship program and their dependents who are admitted in government hospitals, the “No Balance Billing (NBB)” policy of the new system which means no other fees nor expenses shall be charged to or paid for by the patient-member above and beyond the package rate upon discharge from hospitals and non-hospital facilities shall apply, he said.
The NBB policy shall also apply to any other member type such as the employed, individually paying and overseas workers, who will avail themselves of the Maternal Care Package (MCP) and Normal Spontaneous Delivery (NCP) in all accredited MCP non-hospital providers such as maternity clinics and birthing homes.
Among the medical cases and the corresponding package rates, Santelices said are Dengue I, P8,000; Dengue II, P16,000; Pneumonia I, P15,000; Pneumonia II, P32,000; Essential Hypertension, P9,000; Cerebral Infraction I, P28,000; Cerebro-vascular Accident with Hemorrhage II, P38,000; Acute Gastroenteritis, P6,000; Asthma, P9,000; Typhoid Fever, P14,000; and Newborn Care Package in hospitals and lying-in clinics, P1,750.
Surgical procedures on the other hand would include radiotherapy at P3,000 per session and hemodialysis, P4,000 per session while MCP would be at P8,000 but coupled with the NSD package in hospitals classified as Level I for another P8,000 and P6,500 for Levels 2-4 hospitals, he said.
For Caesarian Section, an amount of P19,000 is earmarked while Appendectomy is pegged at P24,000; Cholecystectomy, P31,000; Dilatation and Curettage, P11,000; Thyroidectomy, P31,000; Herniorrhaphy, P21,000; Mastectomy, P22,000; Hysterectomy, P30,000 and Cataract Surgery, P16,000, Santelices added.
Dr. Veronica Mateum, the PhilHealth regional director, meanwhile explained that the selected conditions and procedures were based on the 49 percent of total claims paid by PhilHealth during the previous years and will help further reduce the turnaround payment for reimbursement to medical care providers and members from the current 22 days to a lesser number of days.
This policy was approved after a series of consultations with concerned medical societies and other institutional partners. Its conditions and procedures were also among the top 49 percent of total claims we paid for over the previous years, Mateum said.
With all of these packages in place, the government agency needs about P3 billion for the next six to 12 months once members start availing themselves early next month, she added.