Philhealth Benefits — Medical and Surgical Cases to be Paid on Case Rate Basis

Matagal nang proposal ng Philippine Health Insurance Corp.  (PHILHEALTH or PHIC) ang pagbabayad ng 22 medical and surgical cases on a Case-Rate Basis, at hindi na on a Fee-for-Service basis.  Ibig sabihin, magkakaroon nang fixed Philhealth payment for each of the 22 cases, kahit saang accredited hospital, kahit sinong accredited doctor, at kahit ilang araw ang hospitalization or treatment.

Itong 22 cases ang pinakamadalas na binabayaran ng Philhealth for the past several years. Almost 50 percent daw ng Philhealth claims ay itong mga 22 cases na ito.

Proposal pa lang ito, at pinag-uusapan pa ng Philhealth board. According to some press releases, this Case-Rate-Basis will be implemented SOON.

UPDATE:   Philhealth has already announced that it will start implementing the Case Rates Payment scheme for hospital/clinic admissions starting September 1, 2011.  Certain proposed rates have been increased.  The amounts in blue color are the final rates.

Another UPDATE:  Philhealth announced that the Case Rates payments for surgical cases are applied to hospitalizations in Levels 2, 3 and 4 hospitals only (bigger hospitals),  except for certain cases.

These are the surgical and medical cases, and the corresponding fixed rates or payments/reimbursements by Philhealth.

Medical Cases:

1.  Dengue Fever and DHF Grades 1 and 2  —  8,000 pesos
2.  DHF Grades 3 and 4  —  16,000
3.  Pneumonia 1  —  15,000
4.  Pneumonia 2  —  32,000
5.  Essential hypertension  —  9,000
6.  Cerebral infarction (CVA I)  —  28,000
7.  Cerebro-vascular accident hemorrhage (CVA II)  —  38,000
8.  Acute gastroenteritis (AGE)  —  6,000
9.  Asthma  —  9,000
10.  Typhoid fever  —  14,000
11.  Newborn care package (NCP)  — 1,000  —  increased to 1,750

Surgical Cases:

1.  Radiotherapy  —  3,000 pesos
2.  Hemodialysis  —  4,000
3.  Normal delivery or maternity care package (MCP) in maternity or lying-in clinics  —  8,000

Normal spontaneous delivery (NSD) in Level 1 hospitals  —  8,000
Normal spontaneous delivery (NSD) Levels 2 to 4 hospitals  —  6,500

4.  Delivery by caesarian section (CS)  —  15,000 — increased to 19,000
5.  Appendectomy  —  26,000 — decreased to 24,000
6.  Cholecystectomy  —  31,000
7.  Hysterectomy  —  30,000
8.  Dilatation and curettage  —  11,000
9.  Thyroidectomy  —  31,000
10.  Herniorrhapy — 21,000
11.  Mastectomy  —  22,000

* Note:  For SURGERIES, the Case Rates payment will apply only to cases managed in Levels 2 to 4 hospitals, with certain exceptions.

According to Philhealth, the advantages of Case-Rate-Basis are the following:
– Fixed payments regardless of hospital size and length of treatment
– No more itemization of costs
– Reduction in claim processing costs
– Faster payment of claims
– Lower financial risk for Philhealth
– Reduction of fraud risk

This proposed Philhealth program is also called No Balance Bill Policy because it seeks to cover the full costs of the medical and surgical procedures in accredited government hospitals. Ang gusto nilang mangyari ay lalabas ang pasyente na walang babayaran sa government hospital na Philhealth-accredited.

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