Final FinalTS - PC 35 (IG_ACR)

8/13/2019 Final FinalTS - PC 35 (IG_ACR)

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PhilHealth Circular No. 0035 s. 2013

IMPLEMENTING GUIDELINES ON MEDICAL AND PROCEDURE CASE RATES

- TAMANG SAGOT -

I. CASE RATE PAYMENT SCHEME

1. What is Case Rate Payment Mehanism!

Case Rate Payment is a mechanism utilized by insurance corporations when

reimbursing payment for health care providers, e.g. hospitals and professionals/doctors.

In this system, a single rate which was derived from computations from previous claims

will be given as payment to providers for a particular condition. This system aims toimprove the uality of healthcare and enhance the transparency with the members.

". What a#e the a$%anta&es '( a)) ase #ates!

It improves transparency and predictability. The members can determine the fi!ed

price for a certain case/disease/procedure they will undergo. It ma"es the benefits easier

to communicate to the members. #ll cases will be classified and have fi!ed rates

including the catastrophic diseases which could really help our members.

*. Was the#e a st+$y 'n ase #ates ha%in& ,#'%en that it is m'#e e((eti%e than

S!

$ased on the e!periences of other countries in their payment mechanisms as well

as their insurance systems, there are only a couple of countries who have remained with

fee for service as their payment mechanism. The fee%for%service is an ineffective way of

payment mechanism in insurance companies. It has been shown in previous studies that

the fee%for%service mechanism leads to rapid rise in health insurance premiums &$rantes,

'(()*. It was also mentioned in the same study that this system has failed to promote

coordination among providers or high uality outcomes for patients.

In the local scene, there are a couple of studies that were conducted by +- and

the +orld $an" that compares Case Rates vs. ee%for%ervice. They have concluded that

the Case Rates is better than .

#side from the above mentioned advantages, case%based payments will also ma"e

it easier for the corporation to support the poorest of the poor &sponsored members*

through the 0o $alance $illing Policy.

. What a#e the )imitati'ns '( the +##ent e/istin& ,ayment system!

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The old method of fee%for%service &* had its limitations based on the following1

2. ee%for%ervice payments reuired Philealth to pre%evaluate all claims

received prior to payments. Thus, it was bureaucratic and time%consuming.Philealth processes close to 3,(((,((( claims per year. Therefore, there

were a lot of delayed payments to providers as well. Turn%around%time fromfiling of claims to payment used to be more than )( days, some reaching 4%5

months before getting paid.'. reuired members and providers to understand the benefit table and "now

how to compute for their benefits. This limited the understanding of the

benefits, especially for those who have educational limitations.6. reuired Philealth to compute for benefits. #nd this e!posed the

system to errors in computations. There was also the ris" for discretion of

claims processors in terms of deductions and benefit pay%outs.4. 7espite the payments, the system cannot be complemented with a

regulatory policy that limits out%of%poc"et payments &li"e the no balance

billing policy* because there is a ris" that the providers would 8ust "eepcharging and Philealth would 8ust "eep paying until the ma!imum limit of

the schedule is reached.

3. also created ineuity and unfairness when reimbursing the hospitals since

the costs varied as much as the hospitals applying for reimbursement asdifferent rates were paid for performing one and the same function or using

one and the same process or diagnostic.

0. A#e the#e st+$ies t' $ete#mine h' m+h it i)) 'st +sin& a)) ase #ates

'm,a#e$ t' the ee ('# Se#%ie!

-ur actuary handles the studies and pro8ections as well as the history of claims.They consider the rates for IC7 codes and R9 and compare that with the previous

years. They present the loss as well as the ad8ustments and have concluded that we are

capable of implementing the #ll Case Rates Policy.

II. IMPLEMENTATION

1. Wi)) this 2e im,)emente$ han$ in han$ ith #e%ise$ 2ene(its ('# ,#ima#y a#e

(ai)ities!

The policy for benefits for primary care facilities is discussed in a separate

circular. Please refer to PC 24 s '(26. This circular includes the list of the benefits that

can be claimed for PC.

". What meas+#es a#e 2ein& ta3en t' a$$#ess the iss+e '( $e)aye$ $ist#i2+ti'n 2y the

h's,ita)s '( ,#'(essi'na) (ees (#'m ase #ates!

There is a PIC policy that the hospitals are mandated to issue the professional

fee of the doctors within a month after the hospital received their payment from PIC, as

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stated in the Implementing :uidelines Reports of noncompliance to this provision shall

be forwarded to the Philealth Raegional -ffice &PR-* ealth Care 7elivery

;anagement 7ivision &C7;7* and shall be included as a violation of the CI to the

ealth Care Provider Performance Commitment.

*. I( h's,ita)s +se$ n'n PND $#+&s an$ e e#e a2)e t' ,'st a+$it it4 an h's,ita)a,,ea) i( e ha#&e it t' (+t+#e )aims!

;7 will issue appropriate policies regarding the process flow on post%audit and

penalties and sanctions soon. The proposed process is after post%audit, the report is

forwarded to the hospital and e!planation or 8ustification for findings is demanded. If the

8ustification is sufficient, then no penalty, $ut if 8ustification is unacceptable, CI may be

penalized. -ne option for the penalty is charging to future claims. -nce penalty has been

imposed &whether monetary, or charged to future claims*, CI can no longer appeal.

. Wi)) the system #eset a)) )aims '( mem2e#s an$ ,atients hen it 'mes t' the 0

$ay )imit an$ SPC +,'n im,)ementati'n '( ACR!

+e cannot divulge this to the public. $ut the plan is to reset to minimize the

pressures on the system. owever, this has not been approved by the


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P#'e$+#e8 C)'se$ t#eatment '( #a$ia) hea$ (#at+#e 9R:S '$e8 ";0


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#s mentioned in the $IR issuance in the anne!es, Philhealth is not e!empt from

being a withholding agent of the $IR. In the #ll Case Rate scheme, Philhealth will only

deduct 'A withholding ta! from the facility fee. or the professional fee, the hospital

will be the one responsible to deduct the withholding ta!. #s such, it is also the hospital

who will be responsible to issue the $IR orm '6(). Bindly refer to the e!ample given

below1

Case Rate8 A2sess '( Res,i#at'#y T#at

Case Rate Am'+nt82(,(((

P#'(essi'na) ee86, (((

Ta/ t' 2e ithhe)$ 2y Phi)hea)th8NONE&the hospital is in charge to

deduct the appropriate ta!es

ai)ity ee8),(((

Ta/ t' 2e ithhe)$ 2y Phi)hea)th8),((( ! (.('@ 1< 9"@ '( the (ai)ity

(ee=

;. In the sena#i' that a Phi)Hea)th C)aim as $enie$ an$ its n't the (a+)t '( the

$'t'#. What ha,,ens t' the ,#'(essi'na) (ees!

In this case, the doctor will not be able to receive the professional fee from the

claim. It is the responsibility of the hospital to ensure that the reuirements of claims arecomplete and the forms are properly filled up. It will be the hospital who will be

answerable to the doctor in this case.

>. Wi)) the #ate stay the same $es,ite )en&thy 'n(inement!

es. The case rate is fi!ed regardless of length of stay.

?. A#e me$ia) missi'ns #eim2+#se$ 2y Phi)Hea)th! H' a2'+t s+#&ia) missi'ns!

Claims for medical missions will be denied since only cases which warrant

hospital admission are compensable under the #ll Case Rates scheme. or surgicalmissions, as mentioned in PC 2%'(2', surgical procedure involving cataract e!traction,

cleft lip and palate repair, in%grown toenails and circumcision shall not be compensated.

#s for other procedure, surgical missions conducted at Philhealth%#ccredited government

facilities shall be compensated provided that the professional fees shall be pooled for

distribution to all personnel of the facility.

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B. The#e is n' ase #ate ,a3a&e ('# the ICD '$e I am )aimin&. Wi)) my )aim 2e

$enie$!

+e recognize that the codes included in the case rate are only those from the

benefit utilization data from '((D%'(22. #s of the moment, only the codes listed in the

anne!es will be reimbursed. The conditions and procedures included in the anne!es arethe ones which were already claimed from Philhealth. Providers who encounter such

codes may call the attention of the In%Patient Team so that the case can be reviewed.

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concept of social health insurance in which the premiums of the healthy population is

used to subsidize the healthcare costs of those who cannot afford payment. #ll this is

being done to support the process of achieving >niversal ealth Care.

". What i)) ha,,en i( h's,ita) ha#&es ('# N66 ,atients in &'%e#nment h's,ita)s

e/ee$ the ase #ate am'+nt!

The government subsidy will cover for it. The amount for each case rate was

computed by ta"ing the average of previous claims since '((D%'(22. ince the rates

represent averages, there will naturally be some cases which will e!ceed the computed

rates. owever, there will also be cases which will not be able to ma!imize the rates &ie

total cost will be below the set case rate*. The gains from the cases that fall below the set

case rates should cover for the ones that e!ceed the rates.

:I. MULTIPLE DIAGNOSIS

14 In ases he#e m+)ti,)e ,#'e$+#es a#e $'ne in 'ne a$missi'n4 h' i)) the #ate

2e 'm,+te$!

Computation will be based on first and second case rates, where the former will

be paid in full and the latter paid 3(A if applicable. or now, there are only a limitednumber of procedures that are allowed as second case rate.

". I as a$mitte$ ('# m+)ti,)e $ia&n'ses. H' 'me I i)) 'n)y 2e #eim2+#se$ ('#

'n)y 'ne ase #ate!

or now, we are reimbursing only one case rate. or now, only certain conditions

&;I, tro"e, maternal comorbids* are allowed as second case rates.

codes allowed as second case rate is undergoing feasibility studies and is being

reviewed.

:II. 6URNS

1. The#e a#e $i((e#ent s+#(ae a#eas ('# 2+#ns 9e.&. e#tain 2+#ns that a#e a#'+n$

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$urn case rate as a medical condition will be denied. owever, because simple

debridement is e!empted from the PC, this procedure will be provided.

:III. LYING IN CLINICS

1. Wi)) mi$i%es in )yin&-in )inis 2e 'm,ensate$ ('# #e(e##in& $i((i+)t 7

'm,)iate$ ,#'e$+#es t' hi&he# )e%e) (ai)ities!

es. #ccredited Hying%in clinics will be paid a referral fee of P53(.

". What a#e the 'n)y ,#'e$+#es a))'e$ in a#e$ite$ )yin&-in )inis!

Hying%in clinics are only allowed to perform I>7 insertion and normal low%ris"

delivery as maternity pac"age. -ther complicated procedures such as delivery of high%ris" pregnancies &specific list is detailed in PC '6%'((5 are not allowed in the lying%in

clinics and will not be reimbursed.

I. SINGLE PERIOD O CONINMENT

1. The#e a#e ase #ates that en'm,ass $i((e#ent $iseases. '# SPC4 e +se the ase

#ate. What ha,,ens i( I as a$mitte$ ('# a $i((e#ent ICD 2+t same ase #ate

,a3a&e!

or now, PC covers the case rate pac"age and the second claim will be denied.

+e can propose further brea"down of groups into subgroups in the future once data is

available.

". Patient as &i%en the ase #ate 2ene(it '( ,ne+m'nia an$ st#'3e. A(te# *< $ays4

,atient as a$mitte$ ('# ,ne+m'nia an$ $ie$ $+#in& his 'n(inement. Wi))

,ne+m'nia ('# the se'n$ 'n(inement 2e ,ai$!

ince pneumonia is covered by the PC, unfortunately, his claim for the

pneumonia for the second confinement will be denied.

*. Patient )aime$ MI as (i#st ase #ate an$ st#'3e as se'n$ ase #ate. A(te# 0 $ays4

,atient )aime$ st#'3e as (i#st ase #ate an$ MI as se'n$ ase #ate. Wi)) this sti)) 2e

'%e#e$ 2y the SPC!

es, the PC rule will be applied for both case rates, regardless if listed as first or

second.

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. SPECIIC CASES

1. We +se$ 2e('#e an a&e )imit '( th#ee yea#s ')$ t' i#+misi'n $+e t' ,him'sis.

A#e e sti)) &'in& t' ('))' that in the ase #ate!

There will be no age limit for circumcision due to phimosis. It should be notedthat the indication for payment for circumcision is phimosis.

". On ,e#it'nea) $ia)ysis4 the ,atient 2+ys s+,,)ies (#'m the s+,,)ie# an$ n'

h's,ita) ants t' e#ti(y ('# the )aim. H' i)) this 2e ,ai$!

Circular 5 '((5, all P7 e!changes performed per day shall be charged only 2 day

against the 43 day room and board allowance. Right now, pay as per e!isting policy. The

IPT is in the process of enhancing our e!isting policy. Please give us feedbac"/data

regarding provisions/policies you want to be included.

*. The OHAT Pa3a&e is ,ai$ +sin& the S ,ayment mehanism. What ha,,ens

t' OHAT in a)) ase #ates!

Pac"ages utilizing the mode of payment shall be amended to be consistent

with the all case rates.

. Is the#e a )imit t' the n+m2e# '( sessi'ns '( hem'$ia)ysis that an 2e )aime$!

Technically, we did not set any limits as to the number of hemodialysis sessions.

owever, other reimbursement policies, standards of care and CI behavior will dictate

the number. +e have the 43 days benefit limit so technically, patient may only be

confined for that length of time. tandards of care dictate that dialysis patients can only

undergo hemodialysis about 6! a wee". o in the 43 days ma!imum confinement, patient

may only undergo hemodialysis for about '(!. $ut since this is one confinement and

therefore shall be reimbursed with ma!imum of ' case rates one of which shall be

hemodialysis, the ma!imum reimbursement shall only be about 23(,((( &about )(,(((

for the first case rate and ?(,((( for the dialysis at 4((( per session for '( sessions*. or

a 43%day confinement, this is meager and hospital behavior will eventually limit the

services given to the patient

0. Is hem'the#a,y ase #ate 'n a sessi'n '# y)e 2asis! H' many $ays i)) 2e

$e$+te$ (#'m the 0 $ays!

Chemotherapy case rate is computed on a per cycle basis. one cycle is euivalent

to the amount reflected in anne! ' &)'?(* of the circular and is also euivalent to ' days

deduction from the 43 days. # separate circular will be issued to detail the policies

regarding chemotherapy claims.

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;. Chem'the#a,y an$ ,e#it'nea) $ia)ysis ase #ate $'esnt seem t' 'm,ensate '+#

mem2e#s.

#s mentioned, chemo and P7 are transition policies and thus may not be asresponsive as we want them to be. ;ore comprehensive consultations are being done to

ma"e the case rates better.

>. A#e the#e any Case Rates ith s,ei(i #+)es an$ 'nsi$e#ati'ns!

#. #cute :astroenteritis1 or this case rate, additional codes for the level of dehydration

is reuired, otherwise the claim shall be denied. or #:< with moderate/mar"eddehydration, the code


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". Is the#e a )imit 'n the ases that a#e a))'e$ t' )aim the #e(e##a) ,a3a&e!

#side from the limits on transfers &lower to higher level e!cept H6%H6*, the

referral pac"age also has limits on the cases that may be referred. This is found in anne!? of I:. Those are the only cases that may be allowed to be reimbursed under the referral

pac"age. If the case is not found in the list, then the hospital cannot claim for

reimbursement of the referral pac"age. +hat will happen is the first hospital will file a

full claim and the second hospital where the patient was referred will also file a full

claim. The system should detect an overlap and then $# will decide which of the claims

to pay depending on where more services were done.

*. Re&a#$in& the #e(e##a) ,a3a&e4 h' i)) the ,#'%i$e#s 3n' i( they a#e #e(e##in&

t' a hi&he# )e%e) h's,ita)!

or the referral pac"age, our reuirement is a properly conducted referral. +e

even have a referral form that should be filled out by the referring hospital. $oth these

reuirements force the referring hospital to contact the referral hospital to properly

endorse the patient at which point details of the referral hospital should be determined.

#lso, it is part of the responsibility of the referring hospital to "now the classification and

category of the hospital they are sending their patient to. 7atabases from 7- and

Philealth may also be utilized. Hastly, it is high time that hospitals communicate with

each other for the welfare of the patients.

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Final FinalTS - PC 35 (IG_ACR)