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Issues and Concerns Reported by CARESOctober, 2013

Below is an enumeration o important issues and concerns obser!ed by t"e

CARES deployed in accredited "ospitals durin# October o 2013$ %"is list isbased on submitted reports collated by t"e &'%(CARES$

Membership

1$ Retirees w"o are able to complete 120 mont"s o contribution are notaware t"at t"ey can apply to &"il)ealt" or *ietime members"ip

2$ +&s members allow t"eir relati!es to use t"eir own &"il)ealt" since t"eI- "as no picture$

3$ Sponsored 'embers complain o t"e wron# inormation encoded in t"eir&.C I- t"ey recei!ed causin# problems durin# bene/t a!ailment

+$ Employers data, suc" as &E and Employers ame, o some employees"a!e not yet been updated in our database$

$ I(roup 'embers are unaware t"at t"eir &"il)ealt" members"ip "as a!alidity period$

$ 'ismatc" data on 'ember -ata Record and &"il)ealt" I- o members4$ *)IOs are !ery strict in scrutini5in# t"e supportin# documents submitted

by members especially t"ose under t"e Sponsored6Indi#ent &ro#ram$7$ E8pand t"e &"il)ealt" E8press pro#ram not only in malls but to ot"er

cities and municipalities t"at "a!e "ealt" care acilities so t"at&"il)ealt" is accessible to all9 especially in caterin# to t"e members"ip

concerns, enrolment and :ueries about bene/ts a!ailment$

Contributions

;$ 'embers under t"e Inormal Economy are "a!in# di umaca, ue5on Branc"+A, Bayawan

City Branc" &RO4

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12$ *ate postin# and o!er6under paid contributions in t"e remittancesmade t"ru ACAs$

SRI -asmarinas Ca!ite, Bayad Center Ca!ite Branc"es

'B%C Edsa('a#allanes Branc"

Ban= o Commerce > CR ort" Branc"

&ostal Ban= > &RO 1

Claims/Benefts

13$ 'embers rom t"e ormal sector oten complain t"at t"ey are not#i!en t"e same priority w"en it comes to a!ailability o medicines in t"e"ospital compare to ot"er members$ 'ost o t"eir medicines andsupplies are bou#"t outside t"e acility$

1+$ 'embers oten complained o t"e len#t"y processin# o t"eirreimbursement or reunds$

1$ Increasin# number o Return to )ospital Claims due to e8"austedallowable days or con/nement

1$ 'ember(patients wit" dual members"ip were able to use bot" "iscate#ory types allowin# "im to "a!e a total o ;0 allowable days orbene/t a!ailment$

14$ %"e ewborn Screenin# %est is not a!ailed by members because oinsu

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Obsere% Pra&ti&e/s Cir&ular/s

not"in# to amend$

Re:uirin# t"e submission o certi/cate ocontribution6R1 despite submission o a properlyaccomplis"ed and si#ned C1

o$ 7, s 2004o$ 0, s(2012

on(acceptance o &C1 as a substitute or '-R$ o$ 22, s(2012

on(compliance wit" Senior Citi5en discounts and.A% e8emption

o$ , s(2012

ot allowin# outri#"t deduction o ewborn Care&ac=a#e, )emodialysis, C"emot"erapy, andRadiot"erapy and subse:uently re:uirin# direct/llin# o claims$

o$ 11, s(2011o$ 11B, s(2011

ot compliance wit" t"e BB &olicy o$ 11, s(2011

o$ 22, s(2012

&rescribin# o on(&- medicines o$ 2, s(200;

on(acceptance o &"il)ealt" I- as a solere:uirement or t"e members bene/t a!ailment

o$ 0, s(2012

)ospital as=in# payment or claim orms o$ 12 s$2010

Imposin# a ceilin# amount6 limit on t"e bene/ts omembers in a!ailin# t"e case rate pac=a#es

includin# t"e sponsored pro#ram members

o$ 20, s(2011

&"il)ealt" Bene/ts deducted are not re@ected in t"e

Statement o Account #i!en to members upon

disc"ar#e$

o$ 22, s(

2004

Re:uirin# 'ember -ata Record to +&s member(

patient e!en i t"e +&s I- is on "and

o$ 2+, s(

2012

Health Care Proi%er #elationsSome standards set ort" by t"e Corporation are not ollowed by "ealt" care

pro!iders$ %"e ollowin# are obser!ed or e8perienced by CARES on t"isre#ard$

2+$ )ospitals are still uncertain wit" t"e new IRR, t"ey want us CARES toully e8plain to t"em t"e #uidelines and s"ow circulars beore appro!in#t"e members bene/t a!ailment$

2$ )ospital re:uirin# ot"er documentary re:uirements to member(patient e!en i &"il)ealt" I- is on "and$

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2$ A sur#eon is as=in# indi#ent patients to deposit beore any operationis done$

24$ I)C& &ortal in some "ospitals are not unctionin# and appears to "a!ein!alid account$WHICH HOSPITALS Siruma Muni&ipal Hospital

27$ Cler=s are not aware t"at ewborn Care &ac=a#e can still be a!ailed

to newborns born as t"

c"ild$2;$ Some doctors are not cooperati!e wit" t"e "ospital claims processor9t"ey do not accomplis" t"e C3 properly and on time

30$ %"e "ospital does not "a!e its own p"armacy$ Clients are orced tobuy medicines outside t"e "ospital$

31$ )ospitals as= payment or t"e second Claim orm 1 once t"eycommitted error on t"e /rst /ll up$

32$ )ospitals do not reimbursed receipts rom t"e out o t"e pac=a#ee8penses o members e!en t"ou#" t"e ull case rate amount is not yete8"austed$

33$ -urin# t"e days were t"e CARES is not present in t"e )ospital

Sundays, "ospital are not acceptin# supportin# documentaryre:uirements or a!ailment and ad!ise members to directly /le t"eirclaims$

3+$ )ospital cler=s assi#ned in t"e &"il)ealt" Section do not #i!e uniorminormation to clients and most o t"e time t"is lead to clientFs conusion$%"ose w"o attended t"e trainin# or seminars do not disseminate t"e newpolicies to t"eir collea#ues$

3$ %"e "ospitalFs &"il)ealt" sta< lac= o coordination wit" one anot"er$%"eir speci/c tas=s arenFt well de/ned$ %"eses predicaments resulted inR%)6R%S claims and ine