PhilHealth Subdermal Contraceptive Implant · 2018. 8. 1. · 78,424 94,431 167,915 439,237 780,007 DENIED 3% RTH 2%. TOP REASONS FOR RETURN TO HOSPITAL CLAIMS Manual Claims Not Properly

1

PHILHEALTH

Israel Francis A. Pargas, M.D.

OIC-SVP HFPS

CLAIMS STATUS(Updates)

Yearly Comparative Volume of Claims Received(January to June; 2016 to 2018) 3%

NATIONAL YEARLY CLAIMS PAID COUNT

18%

NATIONAL YEARLY CLAIMS PAID AMOUNT

4%

CURRENT TURN AROUND TIME Nationwide

Top 10 Paid Medical Claims

Circular 2017-0028Length of Stay (LOS) removed as basis for payment of claims for:

Pneumonia

AGE

UTI

• All claims require submission of certified true copy of complete clinical chart (including SEPSIS)

– Claims without complete clinical chart will be returned

EASE OF DOING BUSINESS

CLAIM FORM (CF) 4(PC No.2018 – 0007)

Issues and concerns on patient privacy, administrative cost ,

tedious process etc.

Initiatives Undertaken to Reduce TAT

ADJUDICATORS

TO OPEN FILES in

eCLAIMS

19

min

1

min

CHART CF4

tool containing clinical

(including results of diagnostic tests)

and administrative data

Attached:

laboratory and/or imaging results (scanned or photocopy)

operative room (OR) technique

IMPORTANT POINTS: CF4

****All claims should be accompanied by CF4


CF 4 along with attached lab results and OR record shall replace clinical charts

All claims shall still require CF1 and CF2 or CSF and SOA

The Claim Form 4 (CF 4) replaces Part 1 of the Claim Form 3 (CF 3).

Part 2 of the Claim Form 3 (CF 3) is retained for maternity claims reimbursement

Improperly accomplished or illegible CF4

and/or incomplete attachments

shall be RETURNED to Hospital.


What is not covered by this Circular?

Claims directly filed with PhilHealth

Confinements abroad

Specific packages/ benefits (current requirements still apply):

Z-Benefit packagesOutpatient

HIV/AIDS Treatment (RVS 99246)

Animal Bite Treatment (RVS

90375)

TB-DOTS (RVS 89221 and 89222)

Normal Spontaneous

Delivery ( NSD01)

Maternity Care Package (MCP01)

Newborn Care Package (RVS

99432)

Resuscitation Package (P00000)

Referral Package (P00001)

Medical Prepayment Review : (initial phase)

Pneumonia

AGE

UTI

Sepsis


***PhilHealth reserves the right to subject any and/ or all claims

to medical prepayment review.

PhilHealth shall DENY claims:

over-utilization or under- utilization of services;

unnecessary diagnostic and therapeutic procedures and intervention;

irrational medication and prescriptions;


fraudulent, false or incorrect information as determined by the appropriate office;

gross deviations from currently accepted standards of practice;

inappropriate referral practices;


use of fake, adulterated or misbranded pharmaceuticals, or unregistered drugs;

use of drugs other than those recognized in the latest PNF and those for which exemptions were granted by the Board

unethical patient recruitment

Monitoring of HCPs

• PhilHealth Circular No. 54, s-2012(Provider Engagement throughAccreditation and Contacting for HealthSevices (PEACHes)

• PhilHealth Circular No. 2016-0026 re:(Health Care Provider PerformanceAssessment System (HCP PAS) Revision 1).

Effectivity of CF4

• All admissions starting May 1, 2018 onwards.DEFERRED UNTIL FURTHER NOTICE

as per ADVISORY 0043 2018

May submit any of the Following:

Photocopy of clinical chart

Claim Form 3

Clinical Abstract

Discharge Summary

UPDATES ON PHILHEALTH

Manual Claims Process Flow

e

Manual Receiving

Encoding/Validation Report Printing

Manual Verification/ Adjudication Review

Payment Approval/ Voucher Generation

Voucher Review

Payment Preparation (Check/ACPS)

Check Release/ Crediting to Landbank

End

Start

Hospital transmit

claims to PhilHealth

7 PROCESS

LEVELS

EASE OF DOING BUSINESS

electronic

eClaims System Process Flow

HOSPITA

L

Encode CF1/

CF2 details

e

PHILHEALTH

Assignment of eClaims to Adjudicators

Adjudication Review

Payment Approval/ Voucher Generation

Payment Generation (Auto Credit Payment System)

Crediting of Payment to Landbank

End

Start

SHORTCUT

5 PROCESS

LEVELS

Type of ProcessAverage Days to

Process

Manual 80 days

eClaims 48 days

IMPORTANT

• HCIs partnered with HITP --- CONTINUE

• HCIs with existing HIS/EMR – write to PhilHealth for confirmation and validation of software compliance to PhilHealth requirements

OPTION

• NO HIS/EMR can use PhilHealth Hospital Information and Claims System (PHICS)

or Softcopy Claims System (Sclaims)

IMPORTANT

• Software is certified by PhilHealth as complying to the technical specifications of claims submission and data validation

What is eClaims?

• modular information system

• consists of:

– a front end application for HCIs to conduct claim transactions

– a back-end application for PhilHealth to process claims

What is eClaims?

What is the purpose of eClaims?

•Contains 3 modules:

• Module 1: checks the eligibility of a patient availof PhilHealth benefits

• Module 2: submit claims online

• Module 3: track status of claims

What is eClaims?

Electronic Eligibility

Check (Initial)

ElectronicClaim

Submission

HCI PHIC

ElectronicPayment

ElectronicAdjudication

ElectronicEligibility

Check (Final)

Electronic Claim Status Verification

Module 1

Module 2 Module 4

Module 5

Module 3

HITP

eCLAIMS COMPLIANCE REPORT

JUNE 2018 RECEIVED CLAIMS

Claims Count Manual % eClaims %

1,048,571 116,761 11.14% 931,810 88.86%

REPORT ON MODE OF SUBMISSION PER PRO

PRO Name PHICS PRO ENCODED SCLAIMS HITPCAR 23% 2% 0% 75%

I 2% 3% 0% 95%

II 72% 7% 0% 21%

III-A 15% 4% 0% 81%

III-B 30% 4% 0% 66%

NCR-N 0% 10% 0% 90%

NCR-C 0% 25% 0% 75%

NCR-S 1% 27% 0% 72%

IV-A 0% 7% 0% 93%

IV-B 0% 5% 0% 95%

V 0% 18% 0% 82%

VI 28% 9% 0% 64%

VII 23% 5% 0% 72%

VIII 60% 6% 0% 34%

IX 0% 17% 0% 83%

X 0% 2% 0% 98%

XI 0% 39% 1% 59%

XII 0% 7% 0% 93%

CARAGA 0% 9% 0% 91%

ARMM 0% 8% 0% 92%

National 12% 11.14% 0.06% 77.10%

PhilHealth Advisory 2017 – 0050

• REGISTRATION OF BANK ACCOUNTS FOR THE MANDATORY IMPLEMENTATION OF AUTO CREDIT PAYMENT SCHEME (ACPS)

all accredited Health Care Institutions (HCIs) arerequired to be ACPS compliant for purposes of claimsreimbursements.

What is ACPS?

a payment mechanism where HCI claims are

reimbursed directly into their bank accounts

shortens the time for processing claims by

eliminating check preparation

Will there be transaction charges?

PhilHealth shall not charge fees for auto-credit

payment.

Real-Time Gross Settlement Fees (RTGS)

- Since PhilHealth servicing bank is Landbank,

- HCIs may be charged with RTGS fees if their

servicing bank is not Landbank

RTGS fees shall be shouldered by the HCI

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.

PRO LEVEL1-3 HCIs ACPS Compliant percentageNCR Central 88 88 100%

NCR North 46 45 98%

NCR South 58 57 98%

PRO ARMM 27 27 100%

PRO CAR 25 23 92%

PRO CARAGA 22 22 100%

PRO I 81 81 100%

PRO II 63 63 100%

PRO III-A 87 86 99%

PRO III-B 85 83 98%

PRO IV-A 120 118 98%

PRO IV-B 84 84 100%

PRO IX 33 33 100%

PRO V 52 52 100%

PRO VI 61 61 100%

PRO VII 56 56 100%

PRO VIII 49 47 96%

PRO X 70 70 100%

PRO XI 56 56 100%

PRO XII 61 61 100%

NATIONAL 1,224 1,213 99%

PhilHealth Advisory 2018 – 0017

Philippine National Formulary (PNF) 8th Edition Essential Medicines List (EML) 2017

posted and can be accessed at:

https//www.philhealth.gov.ph/partners/providers/pdf/PNF8thEd_2017.pdf

The new PNF shall be basis for claims reimbursement and performance

monitoring for all admissions starting March 1, 2018.

Download at:

https://www.philhealth.gov.ph/partners/providers/pdf/

PNF8thEd_2017.pdf

ADVISORY No. 2018 - 0042

CLAIMS STATUS REPORTS TO BE SENT TO ALL ACCREDITED

INSTITUTIONAL HEALTH CARE PROVIDERS VIA E-MAIL

assist in the reconciliation of provider and insurer records,

all accredited HCIs shall be provided with a Summary of Claims Status Report (SCSR)

of their claims reimbursements through their official email accounts or addresses.

SCSR contains the status of claims

Paid

pending in process

Denied

Returned to Hospital

PHILHEALTH ABS CBN HOSPITAL

gross

CLAIMS STATUS 2015 2016 2017Jan-June

2018Total

TOTAL RECEIVED 9,026,562 10,701,385 11,004,954 5,647,913 36,380,814

DENIED189,193 277,091 346,223 175,262 987,769

RTH78,424 94,431 167,915 439,237 780,007

DENIED 3%

RTH 2%

TOP REASONS FOR RETURN TO HOSPITAL CLAIMS

Manual ClaimsNot Properly Accomplished SOA

Not properly accomplished CF1/CSF , CF2no attachment of chart (AGE, Pneumonia, UTI & Sepsis)

Proof of contributionIncorrect ICD 10 code or RVS code

CF2 Part II Item #8F, Attach NBS Filter sticker CF2 Part II Item #8F, Tick the services provided for NCP

Discrepancies of mailing address in CF1 vs SOA, Charges in CF2 vs SOA

MDR or CE1 2017 validity for refiled claims. Session Dates in CF2, part 2 -item 8, are not ticked/selected

No supporting documents (e.g. birth certificate of dependent)

TOP REASONS FOR RETURN TO HOSPITAL CLAIMS

Electronic SubmissionNot Properly Accomplished SOA

encoding of CSF & CF2 (not properly accomplished )no attachment of Chart (for PCF, AGE, Pneumonia, UTI & Sepsis)

Wrong encoding of entries in CF2 ( ICD 10 code, RVS code, case rate claimed, degree of dehydration not encoded, dialysis session)

Wrong use of PhilHealth Accreditation Number of Health Care Institution ( Claiming of animal bite package but the HCI used the PAN for PCB

accreditation)Scanned Documents submitted-Unviewable/cannot be loaded

Required Medical Documents (No NBS Sticker and Hearing Test result, No CPSA IOL Sticker)

Discrepancy on charges in Form 2 part III vs SOA

TOP TEN REASONS FOR DENIED CLAIMS

VIOLATION OF SINGLE PERIOD POLICYCASE NOT COMPENSABLE

FILED BEYOND 60 DAYS STATUTORY PERIODCASE RATE CLAIM ATTENDED BY NOT ACCREDITED DOCTOR

CONFINEMENT NOT WITHIN HOSPITAL ACCREDITATION PERIODEXHAUSTED 45 COMPENSABLE DAYS

PATIENT NOT REGISTERED IN PHILHEALTH DIALYSIS DATABASECONFINEMENT NOT WITHIN CLAIM ELIGIBILITY PERIOD

DENIED DUE TO NON-COMPLIANCEINCONSISTENT DATA

MEDICAL CASE RATE ADMITTED LESS THAN 24 HOURSDOUBLE FILING/SAME DAY CONFINEMENT

OVERLAPPING CONFINEMENTEXPIRED VALIDITY

NON-COMPLIANT TO 3/6 RULE

Upcoming Benefits

1. Expanded Newborn Package

2. Rheumatic Fever- Rheumatic Heart Disease benefit package

3. Expanded Primary Care Benefit Package

PCB1 PackagePCB1 Package in Government

Sponsored Program

Organized Groups

Overseas Workers Program

DepEdPersonnel

M E M B E R S a n d D E P E N D E N T S

Expansion of PCB 1

PhilHealth shall expand the Primary Care Benefit to all members and dependents

of the formal sector,

lifetime and senior citizen members

Expansion of PCB 1

private and government health care institutions, including out patient department of hospitals

may proceed to their

respective PhilHealth Regional Offices

for inclusion in their Performance Commitment as an

Accredited Provider for the PCB1 Expansion.

Expansion of PCB 1

coordination with the IT of the

PhilHealth Regional Office

to gain access of the ePCB Module

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