PhilHealth All Case Rate Policy, ROJoson Experience and TPOR

PhilHealth All Case Rate Policy, ROJoson Experience and TPOR

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 private 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 private 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                            P14,400

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 private hospitals, 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).

ROJoson’s Experiences on Case Payment for Operations

In Manila Doctors Hospital, I have observed that it is possible for me to limit the patients’ hospital expenses to the PhilHealth case payment scheme.

At the moment, I can only do it for outpatient procedures.

In particular, at the moment, it is possible for me to limit the patients’ hospital expenses to the PhilHealth case payment scheme for the following cases:

  • those undergoing excision of skin and soft tissue masses without histopathogic examination and use of electrosurgical equipment (case rate: HCI Fee: P2800) [meaning, I can do the operation with the patient’s incurring a hospital expenses of equal or less than P2800)
  • those undergoing excision of breast masses with histopathologic result without the use of electrosurgical equipment (case rate: HCI Fee: p5500) [meaning, I can do the operation with the patient’s incurring a hospital expenses of equal or less than P5500)

In the future, I hope I will be able to get or to list more outpatient procedures that can be done within the PhilHealth case payment scheme.

ROJoson’s Thoughts, Perceptions, Opinions, and Recommendations:

  • PhilHealth offers medical benefits in the form of the All Case Rate Policy, the case payment scheme.
  • Physicians should ride on these benefits for the sake of the patients.
  • Physicians should exert all efforts (best efforts) to keep their patients’ expenses within the set PhilHealth case payment benefit scheme.
  • The All Case Rate Policy, though still needs refinement in the costing, is a prelude to a value-based health care services (keeping the medical expenses as low as possible yet producing excellent medical  outcomes).

ROJ@15sept13

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