Focal Point
PAO President’s Corner
February 10, 2009
On Health Insurance Concerns
There have been a lot of developments on our concerns with Philhealth and various circulars have been released – most of which I had already tackled in my President’s Report to the general assembly in the last general membership and business meeting of the Academy. I am writing this column for the interest of members who have not been adequately clarified on the nuances and predicates of the circulars and for those who have not been in the loop or have not attended the last annual business meeting.
1. Philhealth Circular No. 17 s-2007
- Subject: Discontinuance of Compensability of Claims for Cataract Surgery Performed During Medical Missions and Thru Other Recruitment Schemes and Further Limiting the Number of Compensable Claims for Cataract Surgery
This circular puts into flesh Philhealth Board Resolution No. 1046 s-2007 that discontinues compensability of claims for cataract operations performed during medical missions and other recruitment schemes for cataract surgery.
It also directs Philhealth to employ necessary measures to LIMIT the number of claims for the said procedure which may be compensated under the program by ascertaining the veracity of volume claims prior to processing and payment.
It is the suggestion of Philhealth to raise the red flag of suspected unethical & questionable utilization of insurance fund on surgeons who shall do more than 100 cataract procedures within a year – allocated roughly at about 25 cataract cases per quarter. The PAO is presently questioning and appealing the basis of this figure. Negotiations are on-going on how to deal with the capitation of the number of compensable cataract surgeries per qualified eye surgeon.
2. Philhealth Circular No. 19 s-2007
- Subject: Implementing Guidelines for Philhealth Circular No. 17 s-2007
For the purpose of this policy, Philhealth refers to the definition of the following terms:
· “Medical Mission” or “Cataract Mission” is an outreach program for humanitarian / non-profit purposes that provides free cataract surgery to people of all ages who have limited or no means to pay.
· “Cataract Surgery” is the removal of the lens of the eye that has developed an opacification, which is referred to as a cataract. Following surgical removal of the natural lens, an artificial intraocular lens is implanted. Cataract surgery is generally performed by an ophthalmologist (eye surgeon) at an ambulatory or in-patient setting in a surgical center or hospital using local anesthesia (either topical, peri-bulbar or retro-bulbar) or general anesthesia.
This circular further spells out the only two exceptions to the intent of non-compensability of cataract surgeries done in missions namely: a) PAO endorsed and recognized community-based cataract projects (subject to additional provisions of circular no. 19) and b) NATIONAL GOVERNMENT OR LGU sponsored cataract projects (subject to limitations of conduct of cataract mission (adverse selection, cataract sweepers in all its guises) that are violative of the intent of the circular.
The following are the suggested addendum to the circular based on the MOA with the PAO dated December 9, 2007:
· PAO shall submit to Standards & Monitoring Department (SMD) of Philhealth the list of up-coming PAO endorsed and recognized community based cataract projects for the following year. The letter shall be addressed to the incumbent President & CEO of Pilhealth. The SMD shall furnish appropriate Philhealth Regional Office (PRO) of this information..
· Any additional PAO endorsed and recognized community-based catarcat projects not included in the above mentioned list shall be submitted to the SMD-Philhealth at least three (3) weeks prior to the conduct of the activity.
· The local PAO chapter shall submit to the appropriate Philhealth Regional Office the details of the cataract mission performed as prescribed in the MOA for evaluation, processing and payment of claims within 7 working days from the date of the activity. Failure to submit within this period may result in denial of claims for the attended patients.
· Any list of mission activities submitted by a catarct mission group directly to the PRO shall be forwarded to PAO central office for endorsement.
· Philhealth in coordination with PAO, shall conduct spot checks of missions as needed to monitor the quality of care and to ensure the proper implementation of issuances/policies governing cataract missions involving Philhealth members/patients.
3. Philhealth Circular No. 02 s-2005
a. Subject: Philhealth Guidelines for members and dependents to implement the relevant provisions of Republic Act 9257, Otherwise known as the “Expanded Senior Citizens Act of 2003.”
Pertinent provisions are as follows:
i. Accredited health care professionals SHALL ISSUE to the (senior) member and dependent (60 years old and above) AN OFFICIAL RCEIPT (OR) with the 20% senior citizen’s discount and the Philhealth expected re-imbursement or counterpart explicitly written.
ii. In calculating the Philhealth re-imbursement of professional fees, the health professional MUST FIRST DEDUCT the amount representing the 20% discount from the applicable fees. Only the remaining 80% or a portion thereof – is chargeable to Philhealth.
iii. If the Philhealth member pays for the professional fees in full and opts to claim re-imbursement of professional fees directly to Philhealth through direct filing, the original OR MUST BE ATTACHED to the claim.
iv. In case of UNDER-DEDUCTION of the Philhealth benefit, the DIFFERENCE SHALL BE PAID TO THE MEMBER provided that the original OR is attached.
4. Philhealth Circular No. 14 s-2008
a. Subject: Guidelines on Re-imbursement of Professional Fees and Accomplishment of Philhealth Claim Form 2.
It is the intention of the circular to ensure appropriate payment of professional fees, minimize deficiencies that result to non-payment of PF and avoid disputes / conflicts between the member and the physician as regards re-imbursement of PF. The official receipt is being required per recommendation of the Commission on Audit (COA) in order to determine the exact amount of benefit of the patient deducted from the PF of the doctor and for appropriate re-imbursement to doctor or member. The proper filling up of Claim Form 2 has been emphasized in Circular no. 11 and is being reiterated in circular no. 14. Pertinent provisions of this circular that became effective January 1, 2009 include the following:
· Accredited doctors are required to issue Philhealth invoice or official receipts on professional fees paid by members as PRE-REQUISITE for processing professional fees.
1. If Philhealth benefit was deducted from the actual charge – total charges with the exact amount deducted must be specified in the invoice / official receipt.
2. If no Philhealth deduction was applied, the invoice / official receipt should clearly indicate full payment. Doctors are required to issue professional fee waiver to facilitate re-imbursement of members.
3. It is recommended that the official receipt must be duly signed by the member or his / her representative conforming to Philhealth deductions applied.
5. Philhealth Circular No. 32 s-2006
a. Subject: Implementation Guidelines of Philhealth Board Resolution No. 926 s. 2006 Providing for a Revised Philhealth Benefit Schedule
Effective January 1, 2007 the revised benefit schedule shall implement the following revisions:
· Revised case-typing system from ordinary, intensive and catastrophic to case-types listed as A (RVS 2001 procedures with RVU of 80 and below), B (RVS 2001 procedures with RVU 81 up to 200), C (RVU from 201 up to 500), and D (RVU above 500)
· Unified benefit schedule for all Philhealth member categories including overseas worker members based on level of health care facility: primary (level 1 hospital), secondary (level 2 hospital) and tertiary (levels 3 & 4 hospitals - eg for case tyoe B: drugs & medicines-P9,000; X-ray, lab & others- P4,000; Operating Room: P3,490)
· General rule of fixed case-typing to facilitate transparency and responsiveness which were also instructed by Philhealth Board Resolution no. 899 s-2006
With the above revisions, cataract surgeries (ECCE and phaco-emulsification) are classified presently as case type B : (RVU of 180 and 200 respectively). Likewise professional fees of surgeons are pegged at P40/RVU not exceeding P16,000 while anesthesiologist’s fees are pegged at 30% of surgeon’s fee not exceeding P5,000 for case types A to C per single period of confinement. Comparatively, surgeon’s fee for case type D is computed at (P40/RVU) multiplied by 3 but not exceeding P47,790 while anesthesiologist fee is 30% of surgeon’s fee not exceeding P14,355)
6. Philhealth Circular No. 22 s-2008
a. Subject: Tiered Payment of Professional Fees of Accredited Physicians
This circular which took effect January 1, 2009 provides for the granting of incentives to appropriately trained and qualified physicians by computing their professional fees for surgeries and other RVU-linked services based on a range of PCF (peso conversion factor) depending on claims code group listed in annex a of Philhealth circular no.11 s-2005.
i. Group I (Accreditation Code 1100) – general practitioners & other physicians with no hospital training shall have a baseline PCF of P40.00
ii. Group 5 (Accreditation Codes 1501 to 1503) & Group 6 (Accreditation 1601) – physicians who completed residency training but are not specialty board certified shall have a PCF 20% higher than baseline PCF ~ P48.00
iii. Group 2 & 3 (Accreditation Codes 1201 to 1313) – fellows and diplomats of specialty societies recognized by the PMA shall have a PCF 40% higher than baseline PCF ~ P56.00
iv. It further provides for additional 10% higher payment than the designated PCF for doctors practicing in areas with shortage in health human resources. The list of Philhealth of designated areas will be published in a subsequent issuance.
v. This rule on tiered payment applies only to RVU linked services and does not cover payment for daily visits and management.
This notwithstanding - we have lately been advised by Philhealth Benefits Development & Research Department (BDRD), that while the three tiered payment of accredited physicians for RVU linked services are presently in effect – cataract surgeries will soon be de-listed from these RVU linked services and will thus no longer enjoy the tiered peso conversion factor in the near future. Instead cataract procedures shall be subjected to case-payment system as decided on by the PHIC Board of Trustees similar to other procedures with high utilization rate of Philhealth re-imbursements. Other ophthalmic procedures however shall continue to be RVU linked and thus subjected to the tiered PCF (peso conversion factor).
Quite significantly, your Academy thru the various inputs of our different sub-specialty societies made representation both in 2007 and 2008 to submit our suggested revised RVU for existing ophthalmic procedures and new additional procedures. We have received feelers that the BDRD had acted minimally on our proposed RVU upgrades – since they have decided to implement the tiered payment system instead.
Presently, with the suggestion of many from our board certified members – we are negotiating how to relatively increase the PCF for boarded eyemds compared to those members (associates) who have either not passed the specialty board exam or have chosen not to take the boards at all.
7. Philhealth Circular No. 07 s-2004
a. Subject: Limitations as to the Availment of Keratomilieusis, Radial Keratotomy and Keratoplasty
Our Academy has been asked to comment on this old circular regarding the compensability of LASIK procedures for post-operative surgically induced astigmatism and/or anisometropia. This has been brought to the attention of the Philippine Society of Cataract & Refractive Surgery (PSCRS) and we are presently awaiting their expert opinion on the matter. We shall update you on the developments on this issue.
Finally, while we are on the issue of health insurance matters, please be informed of the on-going efforts of your Academy to propose an increase in the standard AHMOPI basic consultation fee for our specialty to six hundred pesos (P600) from the current two hundred seventy five (P275). Basic ophthalmology consult shall consist of the basic steps of methodical eye examination to include history taking, gross examination, visual acuity, slit lamp examination, IOP, EOMs, funduscopy. In our letter to the PCS, Sub-committee on HMO last 2007 - the proposed Php 600 consultation fee shall include the following examinations:
· Visual acuity testing
· Refraction (when indicated)
· Slit lamp examination
· Intra-ocular pressure determination
· Ophthalmoscopy (direct or indirect as indicated)
· Gonioscopy (may be also be done when necessary)
We have likewise communicated these concerns to the current PMA President who also happens to be the chairman for the PMA Committee on PHIC and HMO. Presently we have tasked our Committee on Health Insurance Matters to further study the other special office consultation procedures that may warrant additional payment as they require further use of specialized instrumentation.