Philippine Medical Association-PhilHealth Forum: Current Updates
By Alma Gay Concepcion Tavanlar Amado, MD, FPDS
If you’re a PDS Dermatologist accredited by Philippine Health Insurance Corporation (PHIC) aka PhilHealth, please visit the PhilHealth website and read circular no. 2018-0014 https://www.philhealth.gov.ph/circulars/2018/circ2018-0014.pdf.
Last August 23, 2018, 1-5pm at the PMA Auditorium in North Avenue Quezon City, PDS President Dr. Ma. Angela Lavadia and PDS Board member Dr. Francisco Rivera, together with Drs. Luisa Puyat, Martha Tapales and myself attended the PHIC Forum that was initiated by the PMA. As PHIC’s envoy, Dr. Shirley B. Domingo, Vice President of Corporate affairs group of PHIC, discussed updates and answered several queries of the different specialty societies. She mentioned several points for easy processing of claims and these were:
- For in-patients, use medicines included in the Philippine National Formulary (PNF).
- For admissions and procedures, in addition to filling up the existing claim forms(CF) 1 to 3 of the PHIC, Claim form 4 (CF4) or the ‘clinical summary’ is now required to facilitate data collection and evaluation of claims for payment. https://www.philhealth.gov.ph/downloads/claim/PhilHealth_ClaimForm4_Guidelines.pdf
- Use the correct and proper ICD-10 codes and case rate codes.
Dr. Maria Christina H. Ventura, chair of the PMA committee on Affiliate Societies, synthesized the forum. The main points discussed were:
- Top 4 case rates reimbursed in the PHIC are AGE, UTI, Community Acquired Pneumonia and Sepsis/Septic Shock
- No balance billing (NBB): This is applicable only for indigent patients, kasambahays, senior citizens and sponsored patients. They are to be admitted in the wards of government hospitals.
- Example: We provide for our kasambahays’ PhilHealth contributions so they can use their PHIC benefits if they develop, for example, an abscess of the limb (ICD code L02.4) and needs to be admitted in the hospital or would be needing incision and drainage for that abscess (RVS code 10060) https://www.philhealth.gov.ph/downloads/kasambahay/Household_Employer_Unified_Registration_Form.pdf
- PHIC is continuously studying if case rates can be increased.
- Philippine National Formulary(PNF) Council takes care of prescriptive drugs and is under the Department of Health and not PHIC; Inclusion of medicines happens every 31st of January and is handled by the Pharmacy Division; Exemptions of medicines happens anytime of the year
- PNF Deduction:
- If the total bill of a patient is equal to the case rate, PNF deduction will apply.
- If the total bill of a patient is HIGHER than the case rate, the non-PNF drug can be charged to the patient’s hospital bill. No deduction will happen.
- First peso deduction is care of PhilHealth.
- HMO will and can cover the non-PNF billing.
- Societies can possibly apply for PNF deductions.