This is a provider payment method that reimburses a predetermined fixed rate for each treated case; also called per-case payment.
Through the case rate form of benefit payment, PhilHealth members will immediately know how much subsidy they can get from PhilHealth for certain medical conditions and surgical procedures in accredited institutional health care facilities. At the same time, using this mechanism will improve the turnaround time for claims processing as it is simpler and easier to administer. PhilHealth will be able to reimburse accredited providers faster. It also means less administrative cost to PhilHealth and to the accredited healthcare facilities.
The computation for fair rates were determined through a process where DRG Casemix tariff rates, contracting rates for public and private tertiary hospitals, and average value paid per claim for preceding years were considered and percentage weights were given to each. These cases make up 49 percent of total claims from preceding years were prioritized to be packaged into case rates.
The new case payments shall take effect for all claims with admission dates starting September 1, 2011 in all accredited providers.
These rates shall be the new reimbursement rates for all the specified cases for all PhilHealth members/dependents.
Reimbursement for the said case rates shall be made directly to the facility inclusive of hospital and professional fees.
The professional fees of all accredited doctors who attended or managed a specific case shall be inclusive to the said case rates.
The allocation for doctors' PF shall be 40% of the total amount for each surgical case rate and 30% for each medical case rate. For hemodialysis, the PF amount of Php 500 per session is allocated.
NBB means that no other fees shall be charged or paid for by the PhilHealth patients beyond the identified case rates. NBB policy generally covers the Sponsored member/dependents of PhilHealth
Among our primary objectives for introducing the case rate packages is to provide optimal financial risk protection especially to the most vulnerable groups which are the poorest of the poor. Through PhilHealth Board Resolution 1441 series of 2010, the NBB policy was adopted for the most common medical and surgical conditions experienced in the country which are identified/specified under the new case payments.
The NBB policy applies only to all PhilHealth Sponsored Program members and their dependents that avail of the specified cases under the following conditions:
The NBB policy shall also apply to any other memberhip type (employed, Individually Paying, Overseas Workers, Lifetime) who will avail themselves of the Maternity Care Package (MCP) and Newborn Care Package in all accredited (MCP) non-hospital providers (e.g. maternity clinics, birthing homes).
Yes. If the Sponsored member/dependent purchased necessary items and services during confinement, the health facility is required to attach the official receipt/s detailing the purchases in the claim application for the said confinement.
Yes, with the discretion of the hospital. The sponsored member can still be admitted in any available room and the NBB policy applies.
The NBB policy will not apply, unless the private hospital voluntarily implements it. The sponsored member/dependents will pay the excess of the hospitalization costs including the PF for the attending physician/s after deduction of the applicable caserates if any.
Yes, accredited providers that violate the NBB policy shall be given appropriate sanctions and penalties by the Corporation.
Level- I Hospitals:
Ambulatory Surgical Clinics (ASCs):
Freestanding Dialysis Centers
PhilHealth shall reimburse all packages if two or more different surgical case rates are performed in separate operative sessions even within a confinement period.
Hospital shall be paid once if the procedure performed has laterality (e.g., cataract), whether done in one or different operative session in a single confinement or different confinement within 90 days.
If the procedure is emergency, payment shall be paid through a fee-for-service scheme based on RVU 30 but if the procedure is considered as non-emergency the claim shall be denied.
Yes, the rule on single period of confinement still applies except for hemodialysis and radiotherapy packages, where availment is on a per session basis but subject to 45-days allowance in a year.
Yes. The member shall shoulder the amount in excess of what we will provide under the new case rate packages except for those covered under the NBB policy in government accredited facilities.
Yes. Whether a member uses up three days or ten days for a particular medical condition, they will still be entitled to the same amount PhilHealth will reimburse to the health care facility the case rate amount indicated in the list.
PhilHealth shall reimburse the medical case rates based on the main condition. Therefore, cases with several co-morbidities shall have no additional payment.
The member is entitled to one package and this will be reimbursed to the referral facility. Cost incurred at the referring facility will be shouldered by the member and the claim filed by the facility will be denied except MCP.
PhilHealth will continue to reimburse those cases through the existing benefit table of fee for service scheme.
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