Issues and Concerns Reported by P-CARES

2nd Quarter, 2014

Below is a summary of issues and concerns observed by the P-CARES deployed in accredited healthcare institutions during the second quarter of 2014. The list is based on submitted monthly reports collated by the PMT-CARES. For reference, it is also indicated if the same issue or concern was reported in the previous 3 calendar quarters. A ( mark means that it was reported while an ( means that it was not.Issues and Concern20132014

3Q4Q1Q

Membership1. PhilHealth Circular 28 s-2013, i.e. a properly accomplished PMRF will suffice as documentary requirement for registration and declaration of dependents, had a positive impact on membership. However, it has been observed that grandparents, nieces, in-laws, siblings, etc. who could not be declared as dependents are added by some members, specifically indigent and sponsored members. Information to correct member records is provided by P-CARES in these instances.(((

2. MDRs and PhilHealth IDs of members, particularly Sponsored and Indigents, contain multiple errors and discrepancies causing problems during benefit availment. Also, there are members who have more than one PINs that are qualified for benefit availment. Some dependents declared in the MDR are active members. Cases like these are referred to the PRO/LHIO by the P-CARES.((

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3. Lifetime members are not aware of the need to change member categories and assume that they will be automatically enrolled as Lifetime Members.(((

4. Most of the sponsored members are not aware that their membership has been renewed by their LGUs. On the other hand, renewal of some members per the LGUs master list is not reflected in the i-CARES system. (((

5. Some members have difficulty securing their MDRs and paying their contributions to the LHIOs due to geographic location.(((

6. Some members complain that they have been repeatedly updating their records but the system remains un-updated. These cases are mostly referred to the LHIOs.(((

7. Members experience difficulty in producing proof of relationship to their dependents. Some hospitals insist on requiring such despite the new guidelines for declaring dependents and benefit availment.(((

8. Unstable IT system was observed as problem in the Point-of-Care Enrollment Program. Some hospitals encounter technical problems which causes delay in the enrollment of clients. There are also data inconsistencies between the ORE system and i-CARES(((

9. There are some hospitals who are willing to implement the POC Program but have budgetary constraints.(((

Contributions

10. Employees, both from the public and private sectors, complain about unposted contributions. Those who have been deducted with contributions for many years are disappointed that their employers did not properly remit PhilHealth contributions.(((

11. The general sentiment towards the premium adjustment is negative. (((

12. Members incurred underpayment due to lack of awareness on the new premium rates. Some accredited collecting agents are also not informed/aware about the said adjustment.(((

13. Some employers remit contributions but fail to submit reports on time.(((

14. Members are disappointed because of the late posting of their contributions paid thru the ACAs. Also, official receipts issued by banks/ACAs to the members do not reflect months and quarter paid or have discrepancies in data entries, e.g. wrong PIN and misspelled names. (((

15. Some members of the formal economy were not properly informed that they should pay their contribution when they are on leave without pay.(((

16. Some employers sign the CF1 of their employees even if they have been hired for less than 3 months.(((

17. There are no accessible collecting agents in some municipalities.(((

18. There are employers who require employees to present a certificate of confinement from the hospital before providing a signed CF1.(((

19. There is a suggestion that the P-CARES and other frontline employees be provided with an interactive list of Accredited Collecting Agents. The list uploaded in the website is not user friendly.(((

Claims/Benefits

20. Compared before, the P-CARES feel that PhilHealth members are more aware of their benefits. They appreciate the simplified reimbursement process under the All Case Rates policy. Also, members appreciate the equitable benefits.(((

21. Members and hospitals appreciate the use of PBEF. It makes benefit availment easier for them. (((

22. Members complain about the prohibition of direct filing. They encounter difficulties complying with the requirements during confinement.(((

23. Members complain about the lengthy benefit reimbursement process from government and LGU hospitals.(((

24. Employers are not familiar with the use of the new Claim Form 1.(((

25. Lifetime Members request for PCB1 benefits. They also suggest PhilHealth coverage for general check-up in Levels 1 to 3 Hospitals.(((

26. There are suggestions to implement a price range for medications, laboratories and other services provided by accredited hospitals to avoid overpricing.(((

27. Members and hospital staff are disappointed that the approval of pre-cataract authorization takes more than 7 days. The lag time causes delays in surgery and rescheduling. Also, most hospital staff are not informed that Saturdays and Sundays are not included in the counting of 7 days.(((

28. A lot of members are not able to avail of the Maternal Care Package since they are not informed that the last 2 out of the 4 pre-natal checkups should be done in the same facility where they will deliver.(((

29. Members complain about the lack of information dissemination effort about the PhilHealth benefits. There are no brochures, flyers or other material about it. According to them, they have never heard of the benefits and the new policies until the P-CARES explained it. (((

30. Hospitals have difficulty adjusting with the ACR policy especially in determining the ICD 10 Codes of some diagnoses. They are requesting PhilHealth to offer more trainings, and seminars on these topics.(((

31. A lot of common medical cases are not included in the ACR Policy. Members are requesting for the increase in benefits for some heart related medical and surgical procedures, oncologic cases and the resuscitation package. There remains a perception that benefits are less under the ACR compared with the FFS.(((

32. A lot of hospitals in the regions still have no HCI portal installed. There are also reports that the Portal is mostly down or inaccessible due to poor internet connection, electrical interruptions, technical problems, and other unexpected circumstances beyond human control. It is also not available 24/7 in some hospitals and on weekends.(((

33. There are problems observed in the HCI portal. First, the restrictive data entry requirement results to errors in encoding which constrains members from availing their benefits. Second, there are instances where the system does not yield any YES or NO response. Third, payments remitted thru some ACAs are not reflected in the PBEF. Fourth, the Portal does not detect whether dependents are already declared by other members or has their own PINs. (((

34. The Circulars enumerated below are commonly not followed by Hospitals.

Observed Practice/s

Circular/s

Supporting documents are required even if PMRF will sufficeNo. 28, s-2013Certificates of contribution/RF1s are required despite submission of a properly accomplished and signed CF1

No. 8, s 2007

No. 50, s-2012

Non-compliance with Senior Citizen discounts and VAT exemption

No. 56, s-2012

Non-compliance with the NBB Policy

No. 11, s-2011

No. 22, s- 2012

Hospital require 6 months of contributions before admission to avail of the PhilHealth benefits.OM no. 0257, s.2013

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Health Care Provider Relations

35. Some hospitals admit patients with inadmissible diagnoses to avail of the PhilHealth benefits or sometimes alter diagnoses.(((

36. Some hospitals ask members to sign a blank Claim Form 2 and some even force members to sign blank statement of account. (((

37. Hospitals are not allowing outright deduction of Newborn Care Package due to incomplete services.(((

38. Some hospitals do not provide Statements of Account to discharged patients. (((

39. Non-accredited doctors attend to PhilHealth members which disqualify them from availing of benefits.(((

40. Some hospitals have inadequate medicines, supplies and laboratory procedures which cause out-of-pocket expenses to indigent members.(((

41. Members complain that hospitals do not provide the breakdown of professional fees in the statement of account. (((

42. Some pharmacies of government hospital are not open 24/7. Members had to purchase medicines outside the hospitals if they are admitted after pharmacy hours, on Sundays and holidays.(((

43. Some hospital staff depend on P-CARES determine the ICD codes. (((

44. Hospitals are not consistent with the implementation of 3 months over 6 months of contribution for benefit availament. Some of them require 9 over 12 months of contribution for surgical procedures.(((

45. Hospital charges are higher for PhilHealth Members compared to non-members which often results to excess billing.(((

46. Some hospital do not honor the PhilHealth CARES Form 1 as a replacement for the MDR (((

47. Some hospitals insist on having members update their Member Data Record in LHIO. Attachment of PMRFs and supporting documents are not allowed. Also, they do not accept the PhilHealth ID as proof of membership, attachment of MDR is required.(((

Consolidated by:

_________________

Richard P. Sonsing

PMT-CARES