2011 revised dialysis benefit schedule

46
Benefits Development and Research Department Philippine Health Insurance Corporation

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Page 1: 2011 Revised Dialysis Benefit Schedule

Benefits Development and Research Department

Philippine Health Insurance Corporation

Page 2: 2011 Revised Dialysis Benefit Schedule

OUTLINE

1 • General

2 • Peritoneal Dialysis

3 • Hemodialysis

Page 3: 2011 Revised Dialysis Benefit Schedule

Payroll contribution

Taxes Payment

Providers

Indigents

Employed Self-employed Pensioners

Page 4: 2011 Revised Dialysis Benefit Schedule

Formally Employed

Compulsory enrollment for those employed in the government and private sectors

Premiums are paid thru payroll deductions equally shared by the employer and the employee

(2.5% of the total salary per law or 1.25% each paid by employee and employer ); subject to a salary cap

Page 5: 2011 Revised Dialysis Benefit Schedule

Overseas Workers

PhilHealth assumed Medicare

functions for OFWs on March 1,

2005

Previously administered by the

Overseas Workers Welfare

Administration (OWWA)

Premium is P900 (around US$19)

per member per year

Page 6: 2011 Revised Dialysis Benefit Schedule

Sponsored Program

For families belonging to the lowest income quartile of the population. P1,200 (about US$25) per family per year shared by the National Government (NG) and Local Government Units (LGUs). The proportion of the sharing depends on the income classification of the LGU.

Page 7: 2011 Revised Dialysis Benefit Schedule

Lifetime

Members who have reached the age

of retirement (generally 60 years

old) and have paid at least 120

monthly contributions become

lifetime members of PhilHealth

without contributing additional

premiums to the Program

Page 8: 2011 Revised Dialysis Benefit Schedule

Individually Paying

Covers the: informal sector (street vendors, drivers, etc) professionals (free-lance lawyers, doctors, etc) individuals who could not be covered by any other programs of PhilHealth

Premium is P1,200 (about US$25) per member per year

Page 9: 2011 Revised Dialysis Benefit Schedule

Coverage extends to immediate family…

Legitimate spouse (non-member)

Children* below 21 y.o., unmarried and unemployed

Parents (biological, step or adoptive) 60 y.o. and above & not covered by NPP

*legitimate, illegitimate, legitimated adopted or stepchildren

Page 10: 2011 Revised Dialysis Benefit Schedule

Eligibility Requirements

Page 11: 2011 Revised Dialysis Benefit Schedule

9/12 Guidelines:

1. Hemodialysis and peritoneal dialysis

2. Chemotherapy administration

3. Radiation oncology services

4. Selected surgeries listed in Annex of Circulars (please refer to www.philhealth.gov.ph)

Exempted from this rule members undergoing emergency dialysis services during hospital confinements.

Page 12: 2011 Revised Dialysis Benefit Schedule

Requirements for Filing

PhilHealth Form 1

• (member & employer)

PhilHealth Form 2

• (doctor & hospital)

Member Data Record (MDR)

• Primary document for all members

Other supporting documents

Page 13: 2011 Revised Dialysis Benefit Schedule
Page 14: 2011 Revised Dialysis Benefit Schedule
Page 15: 2011 Revised Dialysis Benefit Schedule
Page 16: 2011 Revised Dialysis Benefit Schedule

L4

L3

L2

L1

Tertiary

Level 4

Level 3

Ambulatory surgical clinics (ASC) Freestanding dialysis centers (FDC)

Secondary (Level 2)

Primary (Level 1)

Page 17: 2011 Revised Dialysis Benefit Schedule

CASETYPE

Case type is an assessment of complexity of illness assigned to a case after discharge.

It is measured on a four (4) scale system

Fixed on ICD, with exceptions

Page 18: 2011 Revised Dialysis Benefit Schedule

Case Types

Medical Surgical

A Simple 0- 80

B Moderate 81- 200

C Severe 201- 500

D Extreme 501- 600

Page 19: 2011 Revised Dialysis Benefit Schedule

Case-type A B C D

PD, HD, KT

Level 3 & 4 Hospitals (Tertiary)

Room & Board* P500/day P500/day P800/day P1,100/day

Drugs and Medicines** P4,200 P14,000 P28,000 P40,000

X-ray, Lab & Others P3,200 P10,500 P21,000 P30,000

Level 2 Hospital (Secondary)

Room & Board* P400/day P400/day P600/day N/A

Drugs and Medicines** P3,360 P11,200 P22,400 N/A

X-ray, Lab & Others P2,240 P7,350 P14,000 N/A

Level 1 Hospital (Primary)

Room & Board* P300/day P300/day N/A N/A

Drugs and Medicines** P2,700 P9,000 N/A N/A

X-ray, Lab & Others P1,600 P5,000 N/A N/A

Page 20: 2011 Revised Dialysis Benefit Schedule
Page 21: 2011 Revised Dialysis Benefit Schedule

1/5/2012 Free Template from www.brainybetty.com 21

Peritoneal Dialysis Any modalities of PD may be claimed from

PhilHealth by patients registered at accredited PD centers and hospitals

Modalities:

Automated

Continuous ambulatory PD (CAPD)

Page 22: 2011 Revised Dialysis Benefit Schedule

Peritoneal Dialysis 1. All PD exchanges per day = 1 day

2. Claims for PD (Per Single Period of Confinement)

Dialysis solution

Supplies

Laboratory

Facility

3. Maximum 20 liters PD solution per day

4. PF based on RVU

10 RVU x 56 PCF = 560 pesos

To be paid to AP; kidney disease-related management

Page 23: 2011 Revised Dialysis Benefit Schedule

Single Period of Confinement

Re-admissions due to same illness within a 90-day period shall only be compensated within one (1) maximum benefit:

Availment for the same illness or condition which is not separated from each other by more than 90 days will not be provided with a new benefit

Only the remaining benefit from the previous confinements may be availed

Page 24: 2011 Revised Dialysis Benefit Schedule

Expenses Prior to Admission Claims for drugs and medicines; and supplies,

radiology, laboratory and other ancillary procedures purchased prior to admission may be reimbursed only for:

peritoneal dialysis,

hemodialysis,

chemotherapy and

other elective surgeries

Must be supported by official receipts (with TIN) Official receipts must be dated 30 days prior to admission

Official receipts issued by doctors will not be reimbursed

Page 25: 2011 Revised Dialysis Benefit Schedule

BENEFITS LEVEL 4 HOSPITAL

Case Type C PD

Room & Board @ 800/day 0

Drugs & Medicines 28,000

Lab, X-ray, Supplies 21,000

OR Fee @ 20/RVU 0

PF Surgeon @ 10 RVU 560

PF Anesthesiologist @ 40% surgeon’s fee 0

PF Medical Management @ 700/day 0

TOTAL 49,560

Page 26: 2011 Revised Dialysis Benefit Schedule

BENEFITS LEVEL 4 HOSPITAL

Case Type C KT HD

Room & Board @ 800/day 8,000 0

Drugs & Medicines 28,000 28,000

Lab, X-ray, Supplies 21,000 21,000

OR Fee @ 20/RVU 9,600 1,200

PF Surgeon @ 480 RVU 26,800 560

PF Anesthesiologist @ 40% surgeon’s fee

10,752 0

PF Medical Management @ 700/day

5,600 0

TOTAL 109,752 50,600

Page 27: 2011 Revised Dialysis Benefit Schedule

1/5/2012 Free Template from www.brainybetty.com 27

Tip to maximize your benefit!

File only up to

• 3 claims per month or

• 9 claims per 90 days

(single period of confinement)

Page 28: 2011 Revised Dialysis Benefit Schedule
Page 29: 2011 Revised Dialysis Benefit Schedule

45 days consumed in 1 quarter

(45/Q)

45 days consumed

in 2 quarters (22/Q)

45 days consumed

in 3 quarters (15/Q)

45 days consumed

in 4 quarters (11/Q)

1st Quarter 50,000 50,000 50,000 50,000

2nd Quarter 50,000 50,000 50,000

3rd Quarter X 50,000 50,000

4th Quarter X X 50,000

Maximum benefit

50,000 100,000 150,000 200,000

Dialysis Benefit for Tertiary Drugs; Lab, Supplies & Others

Page 30: 2011 Revised Dialysis Benefit Schedule

PhilHealth Circular Nos. 011, 011-A and 011-B, s-2011

Pursuant to Board Resolution No.1441 s.2010

Case payment mechanism for the most common medical and surgical conditions (49% of total claims)

“No Balance Billing Policy” (NBB)

Improve turn-around time for claims processing and payment

Effectivity: September 1, 2011

Page 31: 2011 Revised Dialysis Benefit Schedule

NEW PAYMENT MECHANISM Case Payment Scheme

Hospital payment method that reimburses hospitals a predetermined fixed rate for each treated case

also called per-case payment or packages

Single rate regardless of hospital category and length of stay

Page 32: 2011 Revised Dialysis Benefit Schedule

Cases Rates 1 Radiotherapy 3,000

2 Hemodialysis 4,000

3

Maternity Care Package (MCP) 8,000

NSD Package in Level 1 Hospitals 8,000

NSD Package in Levels 2 to 4 Hospitals 6,500

4 Cesarean Section 19,000

5 Appendectomy 24,000

6 Cholecystectomy 31,000

7 Dilatation & Curettage 11,000

8 Thyroidectomy 31,000

9 Herniorrhapy 21,000

10 Mastectomy 22,000

11 Hysterectomy 30,000

12 Cataract Surgery 16,000

Surgical Case Rates

Page 33: 2011 Revised Dialysis Benefit Schedule

Case rate directly paid to the facility

40% of rate is for PF except for hemodialysis

Allowed only in L2 to L4 facilities, but some may allowed in other facilities: – Completion curettage : L1

– Fractional curettage : L1, ASC

– Herniorraphy : ASC

– Laparoscopic chole : ASC

– Cataract : ASC

– Hemodialysis : FDC

– Radiotherapy : L3 to L4 only

Surgical Case Rates

Page 34: 2011 Revised Dialysis Benefit Schedule

General Rules

Shall follow the rule on single period of confinement

Except for hemodialysis and radiotherapy per session

Page 35: 2011 Revised Dialysis Benefit Schedule

Hemodialysis 90935

Features: @4,000 per session

Outpatient hemodialysis

Includes payment for PF (Php500), dialyzer and epoetin

Not allowed in L1 and ASC

Excluded (pay under FFS): – Hemodialysis during confinements – Peritoneal dialysis – Treatment of acute renal failure – Creation of fistula

Page 36: 2011 Revised Dialysis Benefit Schedule

No Balance Billing Policy

“No Balance Billing” Policy shall mean that no

other fees or expenses shall be charged or paid

for by the patient-member above and beyond

the packaged rates.

Page 37: 2011 Revised Dialysis Benefit Schedule

No Balance Billing Policy

Shall be applied to ALL SPONSORED Program members and/or their dependents for the specified cases under the following conditions:

1. When admitted in government facilities/ hospitals.

2. When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and all non-hospital facilities (e.g. FDCs, ASCs)

Page 38: 2011 Revised Dialysis Benefit Schedule

No Balance Billing Policy

3. Claims for reimbursement of Sponsored members and/or their dependents availing of the following existing outpatient packages:

a) TB DOTS (Php 4,000)

b) Malaria (Php 600)

c) HIV-AIDS (Php 7,500 /qtr or Php 30,000/yr)

All other existing policies/guidelines covering these packages shall remain in effect.

Page 39: 2011 Revised Dialysis Benefit Schedule

No Balance Billing Policy

4. In support of Millennium Development Goals (MDG)

NBB policy shall apply to ALL PhilHealth members and their dependents regardless of membership type in ALL Accredited MCP (non-hospital) providers

This shall cover claims for MCP and NCP

Page 40: 2011 Revised Dialysis Benefit Schedule

NBB APPLICATION

Facility/Benefit Sponsored Non Sponsored

Gov’t Hosp NBB X

Private Hosp X X

MCP NBB NBB

DOTS NBB X

Malaria NBB X

HIV AIDS NBB X

FDC NBB X

ASC NBB X

Page 41: 2011 Revised Dialysis Benefit Schedule

No Balance Billing Policy

Facility should purchase necessary items/services in advance on behalf of the member if drugs, supplies, or diagnostic procedures are not available.

Out-of-pocket payment (OOP) made by members shall automatically be deducted against claims of the hospitals (charged to case rates) with corresponding sanctions or penalties the Corporation may charge.

Require attachment of official receipt/s (ORs) for any OOP made by member (for hospital and/or professional fee)

Page 42: 2011 Revised Dialysis Benefit Schedule

Remember

Number of days allowed per year

45 for the member

Another 45 for all dependents

Page 43: 2011 Revised Dialysis Benefit Schedule

Remember

Number of days per single period of confinement

Page 44: 2011 Revised Dialysis Benefit Schedule

Remember

Days prior to session official receipts honored

Page 45: 2011 Revised Dialysis Benefit Schedule

Remember

Number of days allowed to file claim from date of discharge

Number of days allowed to comply with returned claim

Number of days allowed for PhilHealth to process claims

Page 46: 2011 Revised Dialysis Benefit Schedule