Philhealth Updates 2021

PHILHEALTH UPDATES 2021

Edison Navarro, MD

 

1. PHILHEALTH CIRCULAR 2021-0009: PHILHEALTH COVERAGE FOR OUTPATIENT HEMODIALYSIS BENEFIT PACKAGE TO A MAXIMUM OF 144 SESSIONS FOR CY 2021

POLICY STATEMENT:

1. Patients with CKD 5 shall be allowed to avail of the maximum of one hundred forty-four (144) hemodialysis sessions for CY 2021 based on the prescription of their attending physicians.
2. Patients with CKD 5 shall be registered in the PDD in accordance with PHILHEALTH Circular N0. 2016-007
3. The 91st to 144th additional sessions shall be exclusively used for outpatient hemodialysis
4. Any unused sessions will not be carried over to CY 2022
5. Before the publication of this, Philihealth Circular qualified CKD 5 patients who already used the 91st to 144th HD sessions and whose HD benefits have not yet been deducted from their medical bill may directly file claims with PHILHEALTH Regional /Branch Office or Local Health Insurance Office(LHIO) based on the existing guidelines for directly filed claims
6. Upon publication of this PHILHEALTH Circular, claims on covered hemodialysis sessions shall be deducted from the final medical bill and filed by the Health Care provider
7. There shall be no co-payment for PHILHEALTH members classified as indirect contributors.
8. The Health Care Providers shall be subjected to the rules on monitoring and evaluating performance as provided for in PHILHEALTH Circular 2018-0019: Health Care Provider Performance Assessment System (HCP PAS) Revision.
9. Accredited health care providers shall ensure full compliance to all provisions in performance commitments and rules and regulations governing PHILHEALTH accreditation.
10. If the delay in the filing of claims is due to natural calamities or other fortuitous events, the existing guidelines of the Corporation on the provisions of special privileges to those affected by fortuitous events shall apply.

(THE FULL TEXT OF THE CIRCULAR CAN BE VIEWED AT THE PHIC WEBSITE)

 

2. PHILHEALTH CIRCULAR 2021-0011: Philhealth Payment Recovery Policy

SCOPE: The PPR policy shall cover the following cases.

1. Legal impositions of payment of fines and other pecuniary penalties through deductions of fines  from benefit claims
2. Situations or instances that may warrant payment recovery under the following circumstances:
3. Medical post-audit finding such as but not limited to upcasing or creeping of claims
4. Payment of claims credited to the wrong health facility
5. Payment of claims during lapse or gap in accreditation validity or DOH license validity
6. Payment of claims during the suspension of a particular service, or after removal of a specific service
7. Payment of claims during withdrawal, nonrenewal, suspension of accreditation, or closure of HCP
8. Administrative Discrepancies -overpayment made to HCP in excess of the amount due as a result of

6.1 wrong encoding of benefits package claimed to result in a higher case rate payment

6.2. Downgrade in health facility classification  with a consequent decrease  in the allowable rate amounts (e.g., Level 1 hospital downgraded to a Primary Care Facility)

6.3 Miscalculation of withholding tax

6.4 Overpayment of benefit claims  made under the Debit Credit Payment Method after reconciliation with HCP

6.5 Overpayment of benefit claims made under the Primary Care benefits

 

POLICY STATEMENTS:

1. Under PPR, Philhealth shall facilitate the legal impositions of payment of fines or/ and other pecuniary penalties through deduction of fines from the benefit of the following:
2. The amount of penalty of fine and/or other pecuniary penalties served in the writ of execution
3. The PPR will apply as a way to fulfill the payment through deduction of fines from the benefit of claims if the HCP cannot settle the amount in consideration under the writ of execution
4. Copy of the writ of execution must be given to the PHILHEALTH Regional Office

 

1. For circumstances considered, the PRO shall facilitate payment recovery through the following:
2. Validate before the actual recovery of erroneous payments from accredited HCPs to ensure that the payment the Corporation is trying to recover involves clean claims

2, A letter Notice of Payment Recovery Demand Letter shall be provided to the HCP as presented in Annex A

3. HCP is given 15 days to indicate the options of settlement whether to pay in
4. One time full payment of appropriate amount via over the counter through concerned Philhealth Regional Office
5. Chargeable to PPR payment subject to the approval of Regional Vice President

 

1. That PPR shall be effected on prospective benefit payments to be made to HCP

 

1. The PRO-Benefits Administration Section shall process the recovery of the payment chargeable to PHILHEALTH payments due for release and in process or future claims of the concerned HCP

 

1. The full payment of the benefits claim shall be deducted from the recoverable amount until fully settled. In no instance shall the amount be partially obligated under PPR

 

1. For private HCP, the amount that shall be deducted from the PHILHEALTH reimbursement is net of tax of the case rate /benefit packager being claimed

 

1. There shall be no generation of check and/or crediting of the amount to the HCP bank account for those on Auto Credit Payment System(ACPs) until such time that the amount for recovery has been fully deducted from the HCP reimbursement.

 

1. Any unpaid fine shall be required for full payment from the HCPmopr HCPs responsible officer /owner applying for renewal of accreditation under a new or different name. No accreditation shall be approved until responded HCP pays the full unpaid fine

 

1. Philhealth may employ other means, such as but not limited to, sending demand letters and/or exhaust all legal avenues , including the filing of criminal charges , if warranted to recover the due amount in cases where the HCP ceased to operate such that there are not enough claims due for payment or no more pending Philhealth payment

 

1. Should the HCPs have any contention on the application of the policy or on the payments being recovered from them, the processing of benefit claims shall continue and the PPR policy will not apply pending resolution of the issue by the PRO Legal Unit

 

1. The HCP shall be duly informed through the Notice of Payment Recovery Report reflecting the amount that has been deducted Due to PPR. It shall indicate  details of the claim where the application of payment recovery was made, the amount deducted, remaining amount for charging to the HCPs futiure reimbursements, and reference documents

 

1. Upon publication, the PPR policy shall be communicated and distributed to each accredited health facility through the Local Health Insurance Office, to be acknowledged by the Health facility

 

( The full text of the Circular is available at the Philhealth site)