philhealth subdermal contraceptive implant · 2018. 8. 1. · 78,424 94,431 167,915 439,237 780,007...
TRANSCRIPT
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
IMPORTANT POINTS: 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.
IMPORTANT POINTS: CF4
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
IMPORTANT POINTS: CF4
***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;
PhilHealth shall DENY claims:
fraudulent, false or incorrect information as determined by the appropriate office;
gross deviations from currently accepted standards of practice;
inappropriate referral practices;
PhilHealth shall DENY claims:
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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