ChroniclesPhilHealth

The Official Newsletter of the Philippine Health Insurance CorporationIssue 03, 2015

By Faudia H. Subillaga

Members of the Philippine Health Insurance Corporation (PhilHealth) now have someone to seek advice from,

should they be faced with challenges related to benefits availment.

The PhilHealth Customer Assistance, Relations and Empowerment Staff (PCARES) are ready and willing to assist members who need advice at the point-of-service. They are registered nurses deployed in selected accredited government and private health care facilities nationwide, primarily to provide first-hand assistance to PhilHealth members in need.

They also empower members and health care institutions by keeping them up-to-date on PhilHealth programs and services through information and education campaigns. They are usually stationed near the billing sections of hospitals to make coordination with the hospital’s billing clerks easier.

PhilHealth President and CEO Alexander A. Padilla once described them as the jack-of-all-trade front liners of PhilHealth. “They are committed to provide utmost service to our clients with unconditional care and effort to ensure the availment of the benefits due them,” Padilla said.

PhilHealth CARES: Making Member Experience Delightful

Many have expressed appreciation for and satisfaction with the kind of service that the PCARES provide. “Malaking tulong ang PhilHealth CARES para sa mga miyembro. Sa ganitong paraan, mas komportable at mas madali na ang pag-aavail ng benepisyo sa PhilHealth,” said one member.

They can also help facilitate processing of the hospital’s claim documents and help reduce the incidence of Return-to-Hospital (RTH) claims. They likewise assist indigent and sponsored members who want to avail themselves of the No Balance Billing policy, and of the Point-of-Care enrollment procedures, as well as senior citizens who must be entitled to benefits.

With the PCARES around, why worry?

CORPORATE NEWS

02

New Benefit Packages and Services ShowcasedBy Pinky G. Aragones

Three product developments and innovations at point-of-service, designed to make benefit availment easier and to make premium remittance more convenient for employers

were recently showcased at the Marco Polo Hotel Ortigas.Dubbed “PhilHealth Forward,”

the activity showcased the Middle East Respiratory Syndrome - Corona Virus, Ebola and Dialysis (both hemodialysis and peritoneal) packages; the Health Care Institution (HCI) Portal; and the Employer Premium Remittance System (EPRS).

Coverage for Ebola is P110,000 for the first seven (7) days, and an additional P16,000 per day for the next seven (7) days. Coverage for MERS-CoV is P100,000 for health workers and P50,000 for non-health workers.

Significant adjustments in compensating for hemodialysis and peritoneal dialysis through the case rate mechanism were also made. The available number of days was extended from 45 to 90 per year through a benefit-sharing arrangement between and among principal members and dependents, and the per session rate was rationalized to P2,600.

The HCI Portal makes it easy for accredited facilities to check on the member’s eligibility to avail of benefits. Once the Portal says ‘yes,’ entitlement to benefits is a go.

With the new EPRS, employers especially those with hundreds or thousands of employees nationwide, can now remit their premium contributions online.

4 New Radio Ads Now AiringBy Amelita L. Buted

President and Chief Executive Officer Alexander A. Padilla has always articulated

that PhilHealth’s priority are members, particularly the poor. Added to that are the senior citizens who have been given mandatory PhilHealth coverage in accordance with RA 10645. “Foremost in our minds are the members, before anything else. They are given the utmost priority, especially the indigent and sponsored members,” the PhilHeath chief explicitly said.

Given this pronouncement, four (4) new, 30-second radio advertisements were developed and produced by the Corporate Communication Department in partnership with the Member Management Group, underscoring the importance of the poor, the underprivileged and senior citizens.

Two (2) of the radio ads, ‘Pantawid Pamilya’ and ‘Junior’ narrate the tales of Pantawid Pamilya members of the DSWD and how they can immediately avail themselves of benefits by virtue of their membership. The other two (2) radio ads, ‘Father and Son’ and ‘Leng at Ga’ articulate the common situations that should prompt senior citizens to enrol under the Senior Citizen category through the Office for Senior Citizens Affairs.

Already cleared by the Ad Standards Council, these ads are now hitting the airwaves in all radio placements booked by CorComm and by the Regional Public Affairs Units nationwide.

PhilHealth Taps PLDT for Interconnectivity SupportBy Emelita M. Retuta

PhilHealth recently tapped PLDT Alpha Enterprise to enhance the existing connectivity of its offices nationwide.

At present, 24 Regional and Local Health Insurance Offices (LHIOs) are connected using the Internet Protocol-Virtual Private Network (IP-VPN) technology including the backbone network backhaul for data centers. The remaining LHIOs that are connected via the Internet for daily transactions have limited bandwidth that restricts PhilHealth from delivering prompt services to its members.

With the Secondary Link for PROs and LHIOs project, the number of connected offices will increase to 126, replacing the current Internet connections with IP-VPN technology plus sufficient bandwidth. The improvement will solve the bottleneck in terms of connectivity.

The contract signed with PLDT is a two year-long engagement by virtue of PLDT Alpha Enterprise winning the bid for a telecommunications company that can provide communication links between PhilHealth Head Office and its PROs and LHIOs. The partnership will generally improve connectivity of PhilHealth’s offices thereby translating into faster transaction times at the frontline servicing areas.

NEW BENEFITS

03

Q: What’s new with the PhilHealth dialysis package?

A: Under PhilHealth Circular 024-2015: New PhilHealth Dialysis Package (Revision 1), the new case rate per dialysis session whether hemodialysis or peritoneal dialysis is P2,600.00 and PhilHealth members are now entitled to an extended number of dialysis treatments, whether hemodialysis or peritoneal dialysis, from 45 to 90 days per year, thereby granting them access to better financial risk protection against chronic kidney disease stage 5 (previously known as end-stage renal disease).

Q: How is the extended entitlement made possible?

A: This new development is made possible through a benefit-sharing arrangement between and among the principal member and the dependents.

Q: How does the benefit-sharing arrangement work?

A: This arrangement is exclusive for and may solely be availed of by members undergoing renal replacement therapy for chronic kidney disease stage 5. A member who needs to undergo dialysis treatment may tap into the unused portion of the 45-day allowance of his dependents to enable him to avail of the expanded coverage for dialysis up to 90 days per calendar year.

Q: How much is the per-session case rate for both types of dialysis treatments?

A: The new case rate amount for a session of hemodialysis as well as for four days of PD exchange regardless of number of exchanges in peritoneal dialysis is currently at P2,600.00 and is equivalent to one day benefit availment. The annual benefit that was at P180,000 (45 sessions at P4,000) is now at P234,000.00 (maximum 90 sessions at P2,600.00), with an aggregate increase of P54,000.00

Q: What are included in the per-session rate of P2,600.00?

A: The P2,600.00 case rate amount includes payment for the health care institution worth P2,250.00 and professional fee at P350.00.

For peritoneal dialysis, the package includes PD fluids, PD supplies, disinfection caps and professional fees.For hemodialysis, the package includes machine use, drugs, medicines, supplies and professional fee.

Q: Who may avail of this package?

A: The new dialysis package may be availed of by members and/or their legal dependents with chronic kidney disease stage 5 and are undergoing renal replacement therapy either peritoneal dialysis or hemodialysis under the case rate payment mechanism.

Q: Can a member choose between this new dialysis package and the PD First Z Benefit Package?

A: A member who meets the pre-auhtorization and selections criteria for the PD First Z Package may avail of the said package worth P270,000.00 per year, otherwise, the member is covered by the new PhilHealth Dialysis Package.

Q: When did this new package take effect?

A: PhilHealth Circular 024-2015: New PhilHealth Dialysis Package (Revision 1) took effect starting September 15, 2015.

Basic Q & Aon theNew Dialysis Package

By: Benefits Development and Research Department

The same arrangement shall be applied if the dependent intends to avail of the dialysis package – the unused portion of the 45-day allowance of the principal member may be tapped solely/ exclusively for this purpose. In cases when both the principal member and the dependent need to undergo dialysis treatments, they shall share the combined 90-days (45 days for the principal member and 45 days shared by legal dependents) allowance for each calendar year.

04

They are easily recognizable in their yellow-and-green shirt uniforms. They are friendly, accommodating and can move mountains, so to speak, to make sure that every PhilHealth member who comes to them for assistance are able to avail of the benefits at point-of-service.

They are the PhilHealth Customer Assistance, Relations and Empowerment Staff (PCARES). In these pages, we give you a glimpse of the daily life of the PCARES as they contribute to better

member experience at point-of-service.

PhilHealth CARES Congress in Chateau Royale, Nasugbu, Batangas last August 2015

P CARES from Marawi City explains how the No Balance Billing can be availed of

PhilHealth CARES from PRO XII conducts ward classes on Maternity Care Packages of PhilHealth

By Dianna Marie S. Chua

PCARESActionin

Just In!The PCARES Project recently won in the Philippine Government Best Practice Competition (PGBPC) organized by the Development Academy of the Philippines. There were 27 entries for the PGBPC, and 17 were shortlisted. As PGBPC winner, the PCARES automatically qualified for a slot in the 4th International Best Practice Competition, organized by the Center for Organizational Excellence Research, New Zealand, which was held in Manila late-November. They received a glass trophy for the PGBPC victory.

05

P CARES from PRO VI visits patient to explain the All Case Rates policy

P CARES from PRO NCR explaining the All Case Rates policy on benefit

availments

PhilHealth President and CEO Alexander A. Padilla formally welcomes the participants in the 2015 PhilHealth CARES Summit

P CARES from NCR conducts Information Education Campaign

Senior Citizen’s benefit were also discussed by P CARES from

PRO NCR South

Checking the member’s necessary documents in claiming benefits is the daily routine of P CARES from PRO I

P CARES from PRO II orienting members on programs and benefits at the Out-Patient Department and ward sections of their assigned health care institutions

P CARES from PRO IV B disseminates info materials

06

NEW SERVICES

by: Miramar P. Zabala

PhilHealth Regional Office VIII is consistent in its drive to make the PhilHealth experience of members and dependents positive. This is the premise when PRO VIII

conceptualized the Text BPN, a home grown innovation which aims to provide members with quick information regarding their benefit availment through SMS or text messaging.

BPN or Benefit Payment Notice is a document sent to a PhilHealth member via mail detailing his benefit availment of a recent hospitalization or outpatient procedure. It is through this document that the member will know if the correct amount was deducted from his total bill since he now has the information as to how much PhilHealth paid to the hospital and to the doctor.

It usually takes a long time before the BPN reaches the member. “The desire to provide information to members the fastest way possible and the need to reduce mailing cost are what drove us to develop the Text BPN,” said PRO VIII Vice President Walter R. Bacareza. “This project was launched in November of 2010. Operations were however, interrupted in 2014 due to the effects of Super Typhoon Yolanda. Even with roughly 3 years of operation, PhilHealth has saved close to P2M in mailing expenses,” Bacareza added. The savings is so much more than the required operating cost for the Text BPN facility which is P9,000 per year for the subscription of unlimited texting. So far, members have expressed their satisfaction of receiving their BPN information through text.

Maricar Cator, a member who experienced the text BPN services said she liked it better when information are sent through text as it is quick and readily accessible.

The basic concept of the Text BPN is to secure the cellular phone number/s of the members from the Authorization Slip (to Text) which the hospital attaches to the claim documents submitted to PhilHealth. These cell phone numbers are then encoded in the PhilHealth claims system. Once the claim is paid by PhilHealth, sending of BPNs through text will commence. This process is done with the use of a PRO VIII-developed system called Benefit NOMADS or Benefit Notice Management and Delivery System.

To date, Text BPN is functioning as intended. However, some enhancements are proposed for future consideration such as expanding the mechanism to hospitals and members for texting of returned and denied claims. Another would be to integrate the member’s authorization in the Claim Form 1 allowing PhilHealth to access their cell phone numbers for widespread implementation.

TEXT BPN:Providing benefit availment info to members faster

07

NEW POLICIES

By Michelle S. Nisperos

Since August 1, 2015, health care institutions (HCIs) and professionals who are applying for initial and re-accreditation are required to use the revised Performance Commitment (PC) forms.

Revised Performance Commitment for Hospitals and Doctors

PhilHealth Circular 013, s-2105 was issued to ensure that all accredited institutions and professionals provide safe, quality and affordable health care services to members and their dependents. The circular also covers adjustments on the pertinent laws, rules and regulations, policies and administrative orders, conduct of clinical services, records, preparation of claims and participation in the National Health Insurance Program.

The PC is a document signed by health provider applicants who intend to participate in the NHIP. It stipulates their commitment and willingness to comply with PhilHealth policies on benefits payment, information technology, data management and reporting and referral, among others.

The revised PC form includes Primary Care Facilities and Z benefit packages among the choices of service capability; and TB DOTS, Animal Bite and Tsekap packages for single HCIs for health systems/HCI groups, respectively. These changes have been incorporated in just one form for use of both providers.

Likewise, nurses may now apply for accreditation with PhilHealth as one of its professional providers using the revised PC.

The issuance of the revised form will help PhilHealth strengthen its mechanisms in monitoring the performance of its accredited health care providers and ensure that quality health care services are provided.

The revised PC form may be downloaded from www.philhealth.gov.ph/downloads.

Paalala lang po: ang premium contribution para sa 4th Quarter ay dapat bayaran bago mag-December 31. Maaari itong bayaran sa alinmang accredited collecting partner ng PhilHealth.

Upang hassle-free ang availment ng iyong PhilHealth benefits, panatilihing updated ang inyong contribution.

www.philhealth.gov.phaction center

(02)actioncenter@philhealth.gov.ph

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