PhilHealth All Case Rate Policy and No Balance Billing Policy

PhilHealth All Case Rate Policy and No Balance Billing Policy

Case-based Payment – Payment method that reimburses to health care providers a predetermined fixed rate for each treated case or disease; also called per case payment.

Case rate (CR) – Fixed rate or amount that PhilHealth will reimburse for a specific illness/ case, which shall cover for the fees of health care professionals, and all facility charges including, but not limited to, room and board, diagnostics and laboratories, drugs, medicines and supplies, operating room fees and other fees and charges.

All Case Rates Policy means it is now applicable to all medical conditions and procedures whereas before, it used to apply to only 23 medical conditions and procedures.

Examples: The Statement of Account (SOA) shall reflect the total charges minus the PhilHealth benefit for both the health care institution (HCI) fee and professional fee/s (PF). The SOA shall contain the following information. Please refer to illustrations below.

Illustration 1:

Mr. Y, 34 y/o, employed, admitted for Dengue Fever in an accredited Level 1 hospital. The case rate amount is P10,000 (HCI fee: P7,000 and PF: P3,000).

HCI Charges:

Total HCI charges                                                                             P25,000

Less PhilHealth Benefit for facility charges                            P   7,000

Amount due after PhilHealth deduction                                                P 18,000

PF

Total PF of Doctor X                                                                        P 15,000

Less PhilHealth benefit for PF                                                     P    3,000

Amount due after PhilHealth deduction                                    P  12,000

Illustration 2: Ms. Z, 42 y/o, self-employed was admitted for appendectomy due to a ruptured appendix in an accredited Level 2 hospital. The case rate for appendectomy is P24,000 (HCI fee: P14,400 and PF: P9,600). Doctor A (surgeon) charged P25,000 while Doctor B (anesthesiologist) charged P10,000.

HCI Charges

Total HCI charges                                                                             P35,000

Less PhilHealth Benefit for facility charges                                P 14,400

Amount due after PhilHealth deduction                                      P20,600

PF

Total PF of Doctors A & B                                                              P35,000

Less PhilHealth benefit for PF                                                      P  9,600

Amount due after PhilHealth deduction                                     P25,400

In all hospitals, government and private, particularly the latter, usually the hospital expenses are greater than the PhilHealth benefits granted under the All Case Rate Policy.  Thus, patients have to pay the amount after deduction of the PhilHealth benefits, if they do not have other insurances like the Health Maintenance Organizations (HMOs) and if there is no agreement on No Balance Billing Policy.

The No Balance Billing (NBB) Policy of PhilHealth provides that no other fees or expenses shall be charged or be paid for by the indigent patients above and beyond the case rates set by Philhealth for all medical conditions and procedures.  It assumes that complete quality care to attain the best possible health outcomes is provided under the NBB Policy.

This NBB policy generally covers the PhilHealth sponsored members and their dependents in government hospitals.  Nowadays, all government hospitals implement the NBB for all their service patients with PhilHealth (whether sponsored or not).  NBB is usually not done in private hospitals, unless they voluntary implement it, usually in selected cases.

ROJ@15sept13

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