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Case Rates - Frequently Asked Questions

1. What is case payment?

This is a provider payment method that reimburses a predetermined fixed rate for each treated case; also called per-case payment.

2. Why shift to case rate payments? What advantages will this form of benefit payment bring, especially to the members?

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.

3. How were these amounts determined?

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.

4. When is the effectivity of the new case payments?

The new case payments shall take effect for all claims with admission dates starting September 1, 2011 in all accredited providers.

5. Who are entitled to these new case rate packages?

These rates shall be the new reimbursement rates for all the specified cases for all PhilHealth members/dependents.

6. How will cases be reimbursed?

Reimbursement for the said case rates shall be made directly to the facility inclusive of hospital and professional fees.

7. What will happen to doctor's professional fees?

The professional fees of all accredited doctors who attended or managed a specific case shall be inclusive to the said case rates.

8. How much will be the allocation for doctors' PF?

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.

9. What is "No Balance Billing (NBB) and to whom it will be applicable?

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

10. Why is this being introduced only for Sponsored Program members?

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.

11. What are the conditions for availment of benefits of SP members under the NBB policy?

The NBB policy applies only to all PhilHealth Sponsored Program members and their dependents that avail of the specified cases under the following conditions:

  • When they are admitted in government facilities/hospitals
  • When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and non-hospital facilities
  • When availing themselves of existing outpatient packages for TB-DOTS, Malaria and HIV-AIDS
12. Is the NBB policy also applicable to other PhilHealth membership types?

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).

13. If the Sponsored member under NBB bought drugs and medicines or other supplies, will he be able to reimburse then? How

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.

14. In case a sponsored member/dependent was admitted in a government hospital where the only available room that time for the patient is a private room, can the sponsored member be admitted in any room or private room of a government hospital? Will the NBB policy still apply?

Yes, with the discretion of the hospital. The sponsored member can still be admitted in any available room and the NBB policy applies.

15.What if a sponsored member is admitted in a private hospital? Will the NBB policy still be applicable?

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.

16. Are there sanctions for violations in NBB policy?

Yes, accredited providers that violate the NBB policy shall be given appropriate sanctions and penalties by the Corporation.

17. What are the surgical cases under Case Rate that can be reimbursed in Level 1 hospital? Ambulatory surgical clinics? Freestanding dialysis centers??

Level- I Hospitals:

  • a. D & C (Completion and Fractional Curettage)
  • b. Normal Spontaneous Delivery
    Note: The said case shall be reimbursed as NSD package in Level I hospitals (P8,000)
  • c. Newborn Care Package

Ambulatory Surgical Clinics (ASCs):

  • a. D & C (Fractional Curettage)
  • b. Herniorrhaphy
  • c. Laparoscopic cholecystectomy
  • d. Cataract

Freestanding Dialysis Centers

  • a. Hemodialysis
18.How will hospitals be paid for 2 or more surgical case rates performed in a single confinement?

PhilHealth shall reimburse all packages if two or more different surgical case rates are performed in separate operative sessions even within a confinement period.

19. How will the procedures be reimbursed if a procedure performed has laterality (e.g., cataract)?

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.

20. What will happen to major surgical procedures done in Level 1 hospitals?

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.

21. Is Case Rate covered by the rule on single period of confinement? Will the 45 days allowance apply for caserates?

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.

22. Situation 1: If a member's total hospital fees for dengue I is beyond the case rate amount listed by PhilHealth, will the member shoulder the balance?

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.

23. Situation 2: a member is admitted for dengue I for three days, and another member is admitted for dengue I for five days, will they be entitled to the same case rate amount for dengue I of P8,000.00?

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.

24. What medical cases under Case Rate that can be reimbursed in Level 1 hospital? Level 2 hospitals?

  • a) Dengue I (Dengue Fever and Dengue Hemorrhagic Fever Grades I and II)
  • b) Dengue II (Dengue Hemorrhagic Fever Grades III and IV)
    Note: The said cases managed in Level I hospitals shall only be reimbursed as Dengue I package
  • c) Pneumonia I (Moderate Risk Pneumonia)
  • d) Pneumonia II (High Risk Pneumonia)
    Note: The said case managed in Level I hospitals shall only be reimbursed as Pneumonia I package
  • e) Essential Hypertension
  • f) Cerebral Infarction (CVA I)
  • g) Cerebro-vascular Accident with Hemorrhage (CVA II)
    Note: The said case managed in Level I hospitals shall only be reimbursed as CVA I package
  • h) Asthma
  • i) Typhoid Fever
  • j) Acute Gastroenteritis
  • k) NSD
    Note: In level I hospitals the benefit amount is Php 8000 while in Levels 2-4 hospitals the benefit is Php 6500.
25. For medical caserate, how will PhilHealth pay for a patient admitted for several conditions?

PhilHealth shall reimburse the medical case rates based on the main condition. Therefore, cases with several co-morbidities shall have no additional payment.

26. In case the member was transferred to another hospital, will PhilHealth pay for both facilities?

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.

27. For cases not included in the Case Rates table, how will PhilHealth reimburse those cases?

PhilHealth will continue to reimburse those cases through the existing benefit table of fee for service scheme.