TO prevent potential abuse in the payment mechanism used by the Philippine Health Insurance Corporation (PhilHealth) to reimburse its accredited health care providers, the national health insurer’s Board of Directors called for the adoption of comprehensive strategies that will improve controls in the existing All Case Rates (ACR) system.
Under the ACR, each compensable medical condition or surgical procedure has a fixed, pre-determined amount that PhilHealth pays to its accredited health care institutions (HCIs). The amount is inclusive of hospital charges and professional fees of attending physicians.
During its 13th Regular Board Meeting held on August 29, 2017, the PhilHealth Board prioritized the adoption of actions for immediate implementation such as the removal of length-of-stay (LOS) as basis for reimbursement of claims for Pneumonia, Acute Gastroenteritis (AGE) and Urinary Tract Infection (UTI); requiring all claims for these conditions to be supported with clinical charts; for these claims to undergo pre-payment medical review; and inclusion of other conditions to be subjected to pre-payment review and submission of clinical charts, if warranted.
Likewise, the PhilHealth Board required PhilHealth’s Top Management to conduct further staff work on other recommendations, such as the development of a costing framework and manual to be used as guide in the adjustment of rates; strengthening of the claims review process and the monitoring of health care providers; stricter enforcement of control mechanisms; and the shift to more efficient provider payment mechanisms.
This move by the PhilHealth Board is also aimed at protecting members and ensuring quality healthcare. It serves to ensure that PhilHealth beneficiaries need not undergo unnecessary procedures and treatment that may be required by unscrupulous practitioners just to claim higher reimbursements for social health insurance coverage. (END) (END)
(Reference: Dr. Israel Francis A. Pargas, Head Executive Assistant and Concurrent OIC-Vice President for Corporate Affairs Group, Cel No. 0917-8089399)