PHILHEALTH

UPDATES

ISRAEL FRANCIS A. PARGAS, M.D.

Acting Senior Vice President
Health Finance Policy Sector
 Outline

I. Updates on Benefits
II. Updates on Claims Processing
III. Updates on Accreditation
I. Updates on Benefits

NEW

Children with
Disabilities
 Benefit Packages for CWDs

Benefit
Benefit Benefit Benefit
Package for
Package for Package for Package for
Develop
Mobility Visual Hearing
mental
Impairment Disabilities Impairment
Disability
EXPANDED PRIMARY CARE
BENEFIT PACKAGE

P.C. No. 2018-0017

 EXPANSION OF THE PRIMARY
CARE PACKAGE (EPCB) TO COVER
FORMAL ECONOMY, LIFETIME
MEMBERS AND SENIOR CITIZENS

P.C. No. 2018-0017

23.0 M
(39.5M) Expansion

7
 ePCB Package
Essential
Health Services
Screening
and Complete dose
assessment/ of medicines
Average
consultation 800.00
(Risk based
capitation
fee)

8
 PCB Providers
Non-
Private medical
outpatient clinics hospital
facilities
(ASCs and
infirmaries)

Level 1,2 and 3 government and private hospitals

9
 Covered
Disease
Conditions

AGE, UTI, URTI,

Pneumonia (Low Risk),
Asthma, HYPERTENSION,
DIABETES MELLITUS TYPE II

10
 Benefit
Inclusions

•Health screening and

assessment
•Diagnostics: (CBC, Urinalysis,
Fecalysis, Lipid Profile, FBS,
Chest X-ray, Sputum
microscopy, OGTT, Paps
smear/VIA, ECG)
•Complete dose of medicines
for the covered disease
conditions 11
 Requirements for ePCB HCI
• Passed the accreditation
standards
• Installed and operational
electronic reporting
system (online or offline)
• Extended consultation
hours (until 9:00 pm on
week days & week ends)

12
 VARIABLES EXPANDED PCB
Payment Capitation PLUS fixed co-payment
Mechanism
Average of Php 800.00 per family per year
Benefit Package (Risk-based capitation)
Amount SC/LF – Php 900.00 per family per year
FE – PhP 700.00 per family per year

Targets for Assignment (60%)

payment release Achieve at least 4 performance targets (40%)

Recording and Electronic PCB data recording system

Reporting
13
14
15
16
17
BENEFITS IN THE PIPELINE

EXPANDED
NEWBORN
CARE
PACKAGE
BENEFITS IN THE PIPELINE
Outpatient
Benefit for
Rheumatic
Heart Disease
II. Updates on Claims Processing

CLAIMS STATISTICS
AREA2 AVERAGE CLAIMS RECEIVED Ave.
NCR-North NCR-Central NCR-South PRO Daily
Received
IV-A IV-B V
NCR-
2,466
North
11% 16% NCR-
3,410
Central
NCR-
2,297
South
16%
IV-A 3,185

IV-B 2,434
22%
V 1,691

20%

15%
Comparative National Yearly Received Claims January -August

7,806,329

12%
increase
from
7,306,805 2016

6,973,234

2016 2017 2018

 2018 monthly claims received nationwide
1,400,000
23%
31%increase
inceasefrom
fromJanuary
jan
received
1,200,000

1,000,000

800,000

600,000

400,000

200,000

Jan Feb March April May June July August

Jan Feb March April May June July August

815,574 805,631 1,043,578 856,177 976,729 1,045,335 1,170,533 1,003,319

 TURN AROUND TIME
Number of days to process claims
from general receiving to Check
Generation
As per IRR: 60 days
2018 NATIONAL TURN AROUND TIME

68 days

44 days

JANUARY AUGUST
 2018 MONTHLY TURN AROUND TIME PER REGION

PRO JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY AUGUST

NCR-North 60 50 32 34 30 36 36 31

NCR-Central 84 77 77 72 59 53 44 42

NCR-South 32 40 31 48 59 55 49 50
IV-A 51 55 54 83 63 65 47 20
IV-B 52 65 63 63 96 59 58 50
NATIONAL 68 61 53 59 63 60 56 44
 Turn Around Time per HCI Sector

58 days

56 days

government private
 TURN AROUND TIME
MODE of SUBMISSION

83 days

37 days

manual eclaims
Initiatives Undertaken to Reduce TAT
• Claims processing
through eClaims
submission

 HITP (third party)

 PhilHealth Information
Claims System (PHICS)
 Sclaims
 ADVANTAGES of eCLAIMS Submission
HCI PHIC
E
Electronic
Claim
Submission
C Electronic
Adjudication
Module 2
L Module 4

Electronic Electronic
Eligibility
Check (Final)
Claim Status
Verification
A
Module 3 I
Module 1
Electronic
Eligibility
M Electronic
Payment
Check (Initial)
S Module 5
ACPS
 2018 Monthly National ECLAIMS COMPLIANCE
manual eclaims
120%

100%

80%

60%

40%

20%

0%
jan feb march april may june july aug

mode jan feb march april may june july aug

manual 67% 48% 42% 16% 9% 6% 3% 2%
eclaims 33% 52% 58% 84% 91% 94% 97% 98%
Initiatives Undertaken to Reduce TAT

• Electronic Payment
through

Auto Credit
Payment Scheme
(ACPS)
What is the implication of ACPS Noncompliance?

PhilHealth Circular No. 2017-0020

All Claims of noncompliant facilities to ACPS
shall be processed by the PROs until check
generation but the printed checks shall
not be released to the HCIs until
they have complied with the
requirements of the ACPS policy.
 LUZON ACPS COMPLIANCE PRO % compliance

NCR Central 100%

126124
NCR North 98%

NCR South 100%

88 88 87 86 85 83 84 84
81 81 PRO CAR 96%

63 63 61 61
PRO I 100%
57 57
52 52
47 46 PRO II 100%

PRO III-A 99%

25 24

PRO III-B 98%

PRO IV-A 98%

PRO IV-B 100%

HCIs ACPS
PRO V 100%

PRO VI 100%
 Comparative Yearly Paid Claim Count January-August

7,243,272

8%
increase
from year
2016

6,718,374 6,706,822

2016 2017 2018

 Comparative Yearly Paid Claim Amount January-August

70,068,123,968.11

7%
increase
from year
66,595,737,390.05 2016

65,235,083,332.47

2016 2017 2018

Comparative AGEING of PAID CLAIMS
January 2018 AUGUST 2018

21%

51% 49%
79%

<60 days >60 days <60 days >60 days

 2018 monthly ageing of paid claims nationwide
90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

jan feb march april may june july aug

within 60 days more than 60 days

AGEING jan feb march april may june july aug

within 60
51% 58% 70% 66% 61% 65% 71% 79%
days
more than
49% 42% 30% 34% 39% 35% 29% 21%
60 days
PERCENTAGE OF PAID CLAIMS HCI SECTOR
government private

42%
58%

HCI Sector count amount

government 3,084,628 30.8M
private 4,315,508 40.7M
 Avenues to Reconcile Paid and Unpaid HCI claims

 Summary of Claims Status Report (SCSR)

submitted to facility through email
 Reconciliation Summary Module (RSM)
accessed through HCI Portal
PHILHEALTH ABS CBN HOSPITAL

gross
JASPERSAM MEDICAL
CENTER

JASPERSAM MEDICAL
CENTER

HFPS Forum, <date>

REMINDERS:

PAYABLES :
CLAIMS IN PROCESS

NON-PAYABLE :
DENIED CLAIMS
RTH CLAIMS

UNLESS REFILED
 2018 Monthly RTH DENIED claims nationwide

jan feb march april may june july aug

RTH denied

January February March April May June July August

RTH Denied RTH Denied Denied Denied Denied RTH RTH Denied Denied Denied Denied RTH RTH Denied

4% 4% 5% 5% 7% 5% 9% 5% 10% 5% 8% 4% 6% 2% 8% 1%
 PRO January February March April May June July August

RTH Denied RTH Denied Denied Denied Denied RTH RTH Denied Denied Denied Denied RTH RTH Denied

NCR-N 5% 4% 11% 5% 10% 5% 14% 4% 12% 5% 6% 2% 1% 1% 4% 1%

NCR-C 2% 4% 2% 4% 3% 4% 15% 4% 22% 5% 10% 4% 4% 2% 12% 1%
NCR-S 6% 3% 9% 3% 18% 3% 21% 6% 23% 6% 20% 4% 6% 1% 10% 0%
IV-A 3% 3% 9% 7% 10% 11% 12% 10% 14% 5% 14% 4% 12% 3% 13% 1%
IV-B 2% 2% 4% 3% 4% 2% 8% 2% 6% 2% 2% 1% 2% 0% 5% 0%
V 4% 12% 4% 15% 5% 17% 6% 11% 18% 15% 18% 11% 16% 6% 11% 2%
national 4% 4% 5% 5% 7% 5% 9% 5% 10% 5% 8% 4% 6% 2% 8% 1%
TOP REASONS FOR RETURN TO HOSPITAL CLAIMS

Electronic Submission
Not Properly Accomplished SOA

encoding of CSF & CF2 (not properly accomplished - attached files)

no attachment of Chart (for PCF, AGE, Pneumonia, UTI & Sepsis

Wrong use of PhilHealth Accreditation Number of Health Care Institution

(eg. Claiming of animal bite package but the HCI used the PAN for PCB
accreditation)

Require properly accomplished valid claim signature form

Scanned Documents submitted-Unviewable/cannot be loaded
Required Medical Documents (No Clinical chart attached, No NBS
Sticker and Hearing Test result, No CPSA IOL Sticker)
Discrepancy on charges in Form 2 part III vs SOA
Failed the membership data validation check
TOP REASONS FOR DENIED CLAIMS

VIOLATION OF SINGLE PERIOD POLICY

CASE NOT COMPENSABLE AS PER CIRCULAR

FILED BEYOND 60 DAYS STATUTORY PERIOD
CASE RATE CLAIM ATTENDED BY NOT ACCREDITED
DOCTOR
CONFINEMENT NOT WITHIN HOSPITAL
ACCREDITATION PERIOD
LENGTH OF STAY (LOS) REQUIREMENT NOT MET

EXHAUSTED 45 COMPENSABLE DAYS

PATIENT NOT REGISTERED IN PHILHEALTH DIALYSIS
DATABASE
CONFINEMENT NOT WITHIN CLAIM ELIGIBILITY
PERIOD
MEDICAL CASE RATE ADMITTED LESS THAN 24
HOURS
DOUBLE FILING/SAME DAY CONFINEMENT
OVERLAPPING CONFINEMENT
EXPIRED VALIDITY
NON-COMPLIANT TO 3/6 RULE
Claims without SOA
Circular 2017 0014
TB DOTS
Malaria package
OHAT
Z Benefit package
III. Updates on Accreditation

ACCREDITATION STATS AS OF
August 2018
 CY 2018
140

120

100

80
Count

60

40

20

0
ARM CARA
NCR I II III IVA IVB V VI VII VIII IX X XI XII CAR
M GA
L3 57 4 1 10 3 4 3 9 9 2 1 2 5 3 0 2 0
L2 44 23 13 43 49 20 17 16 15 8 8 22 19 15 2 5 10
L1 92 54 49 119 77 60 33 37 34 39 25 46 33 43 29 18 12
INF/DISP 37 36 34 35 26 46 56 30 51 39 28 41 60 55 17 32 33
ASC 79 7 7 19 7 2 3 5 7 2 2 3 6 3 0 2 4
FDC 113 19 10 55 29 16 10 12 14 10 3 7 13 5 0 5 4
 CY 2018
450

400

350

300

250
Count

200

150

100

50

0
ARM CARA
NCR I II III IVA IVB V VI VII VIII IX X XI XII CAR
M GA
PCB 424 129 93 277 93 118 103 134 157 174 77 106 52 48 110 94 67
MCP 352 129 114 278 283 102 176 117 200 216 91 120 154 127 135 95 80
DOTS 262 149 101 191 74 94 69 140 142 170 73 78 55 42 110 93 73
ABTC 29 32 26 36 48 30 20 35 31 28 20 5 9 19 6 28 8
 Professionals, 2010 to 2018 (March 31, 2018)
35000

30000

25000

20000
Number

15000

10000

5000

0
2010 2011 2012 2013 2014 2015 2016 2017 2018
Physician 21529 23390 26358 27070 30812 32008 29822 29860 30135
Dentist 177 201 232 242 356 384 338 328 331
Midwife 354 518 824 1195 2159 1984 1654 1581 1579
Most Common Reasons for Denial of
Accreditation of HCIs
1. Violation of IRR Section 158A (Code Substitution) and
Section 158B (upcoding or upcasing or diagnosis creeping)
2. Violation of IRR Section 151 Claims for non admitted or non
treated patients
3. Non-compliance to multiple deficiencies of QA standard of
care within the 60-days grace period.
4. Non-compliance to NBB policy
5. Lack of 3 years working experience of Medical Director
6. Denied due to expired ABTC certificate
7. Lack of manpower
8. Professional provider with expired accreditation
9. Non-submission of audited financial statement CY 2016
10. Breach of Performance of Commitment
Most Commons Reasons for denial of
Accreditation of Professionals
1. Claims for non-admitted/non-treated
patients
2. Misrepresentation
3. Other Integrity Issues based on adverse
findings
4. for midwives: Admission of high risk patients
(<19 and >35 y/o)
 Recent Issuances
PC 2018-0014
• Contains policy on Medical
Prepayment Review:
(admissibility and use of
non-PNF)
– Use of CF4 on all claims
– Admissibility criteria for 4
conditions
– Deduction of applicable
amount to claims with non-
PNF drugs
• Effective for admissions
starting September 1, 2018.
Clarification on Deferment

• Also includes deferment of deduction

of PNF drugs, however, monitoring will
continue (status quo) until further
notice
 Health Care
Professional Portal

Monitor/Track PhilHealth
benefits of patients
Check status of claims filed by
health care facilities and date of
reimbursement
Register thru
https://partners.philhealth.gov.ph
• Distribution of the reimbursement
within thirty (30) calendar days
from the date of receipt of the
same by the HCI…
• Subject to monitoring thru HCP
PAS
PhilHealth Circular No.0035, s. 2013
(ACR Policy No. 2)
 IDC Digital Transformation Awards 2018

Information Visionary Leader

(PhilHealth)
Digital Transformation Leader
(CIO Jovita Aragona)
The best way to find
yourself is to lose yourself
in the service of others…

Mahatma Gandhi

69
For comments, suggestions,
questions:

Email us at
actioncenter@philhealth.gov.ph