The PhilHealth benefits for “excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion or nipple lesion, (except for gynecomastia), male or female, one or more lesion” consist of the following:
- Health care institution fee: P5500
- Professional fee: P2520
My recent experience (2016 Jan) with Manila Doctors Hospital Operating Room Complex showed that the hospital expenses can be fully covered by the PhilHealth benefits.
Total hospital expense: P5224.66 [breakdown into: operating room complex expense: P2960.98; pharmacy: P103.68; and laboratory (histopath): P2160.00].
Operation done: excision of breast mass under local anesthesia and outpatient
My perception is that in most private hospitals, most patients with PhilHealth still shell out money to pay hospital expenses as these usually exceed the PhilHealth case rates. The no-balance-billing is not applicable to private hospitals.
I and my patient are happy that the PhilHealth benefit was able to cover the hospital expenses of the breast mass excision. (Note: there is still an excess of about P300 on the PhilHealth benefit which automatically goes to the hospital.)
The trick in keeping the hospital expenses of a patient within the limit of the PhilHealth case rate consists of being aware first of the amount of PhilHealth benefit and then compassionate maneuvers to be done by the surgeon in keeping the cost down without necessarily sacrificing the quality outcome of the operation. Examples of such maneuvers: avoiding excessive use of sponges; keeping the operation minimally bloody as much as possible; avoiding use of surgical equipment and materials that are not strictly needed; use of inexpensive sutures; etc.
It goes without saying that the key contributor to keeping the hospital expenses within the PhilHealth benefits is the surgeon.