3rrdd quarter

7/25/2019 3rrdd Quarter

1/13

Issues and Concerns Reported by P-CARES3rd Quarter, 2014

Belo !s a su""ary o# !ssues and concerns obser$ed by t%e CARES deployed !naccred!ted %ealt%care !nst!tut!ons dur!n& t%e t%!rd 'uarter o# 2014( )%e l!st !s basedon sub"!tted "ont%ly reports collated by t%e P*)-CARES( +or re#erence, !t !s also!nd!cated !# t%e sa"e !ssue or concern as reported !n t%e pre$!ous 4 calendar'uarters( A "ar. "eans t%at !t as reported %!le an "eans t%at !t as not(

Issues and Concern2013 2014

3Q 4Q 1Q 2Q

Membership1( P%!l/ealt% C!rcular 2 s-2013, !(e( a properly acco"pl!s%ed

P*R+ !ll su!ce as docu"entary re'u!re"ent #orre&!strat!on and declarat!on o# dependents, %ad a pos!t!$e!"pact on "e"bers%!p( /oe$er, !t %as been obser$edt%at &randparents, n!eces, !n-las, s!bl!n&s, etc( %o couldnot be declared as dependents are added by so"e"e"bers, spec!cally !nd!&ent and sponsored "e"bers(In#or"at!on to correct "e"ber records !s pro$!ded by P-CARES !n t%ese !nstances(

2( *Rs and P%!l/ealt% Is o# "e"bers, part!cularlySponsored and Ind!&ents, conta!n "ult!ple errors andd!screpanc!es caus!n& proble"s dur!n& benet a$a!l"ent(

Also, t%ere are "e"bers %o %a$e "ore t%an one PIst%at are 'ual!ed #or benet a$a!l"ent( So"e dependentsdeclared !n t%e *R are act!$e "e"bers( Cases l!.e t%eseare re#erred to t%e PR567/I5 by t%e P-CARES(

3. Ret!rees are not aare o# t%e need to c%an&e "e"bercate&or!es and assu"e t%at t%ey !ll be auto"at!callyenrolled as 7!#et!"e *e"bers(

4( *ost o# t%e sponsored and !nd!&ent "e"bers are notaare t%at t%e!r "e"bers%!p %as been reneed( 5n t%eot%er %and, reneal o# t%ese "e"bers ere not re8ected!n t%e !-CARES syste"(

9( So"e "e"bers %a$e d!!culty secur!n& t%e!r *Rs due tot%e!r &eo&rap%!c locat!on(

6. )%ere are "e"bers %o are already e"ployed #or se$eral"ont%s6years but st!ll do not %a$e PI(

:( )%ere ere so"e P%!l/ealt% "e"bers report!n& t%at so"eo# t%e!r declared dependents ere o"!tted !n t%e!r *R,t%ose dependents are t%ose !t% %!story o# benet


2/13


3Q 4Q 1Q 2Q

a$a!l"ent(

( So"e "e"bers co"pla!n t%at t%ey %a$e been repeatedly

updat!n& t%e!r records but t%e syste" re"a!ns un-updated(

;( *e"bers eor.ers eas!ly appro$e P5C "e"bers%!p e$en t%ou&% t%epat!ent !s not cons!dered as an !nd!&ent6cr!t!cal poor(

14( >!t% t%e !"ple"entat!on o# 36? "ont%s o# contr!but!ons#or benet a$a!l"ent, an !ncrease on "e"bers%!p asobser$ed espec!ally pre&nant o"en(

15.*e"bers ere unaare t%at t%ere are P%!l/ealt% E


3/13


3Q 4Q 1Q 2Q

19.*e"bers are d!sappo!nted because o# t%e late post!n& o#t%e!r contr!but!ons pa!d t%ru t%e ACAs( Also, o!c!alrece!pts !ssued by ban.s6ACAs to t%e "e"bers do not

re8ect "ont%s and 'uarter pa!d or %a$e d!screpanc!es !ndata entr!es, e(&( ron& PI and "!sspelled na"es( 7astly,o$erlapp!n& o# contr!but!ons ere also obser$ed(

20( So"e ACAs rece!$ed retroact!$e pay"ents #ro" t%e"e"ber e$en t%ou&% t%e "e"ber !s not any "ore alloedto pay #or t%e "!ssed 'uarter

21( So"e "e"bers o# t%e #or"al econo"y ere notproperly !n#or"ed t%at t%ey s%ould pay t%e!r contr!but!on%en t%ey are on lea$e !t%out pay(

22( So"e e"ployers s!&n t%e C+1 o# t%e!r e"ployees e$en !#t%ey %a$e been %!red #or less t%an 3 "ont%s(

23.So"e "e"ber e


4/13


3Q 4Q 1Q 2Q

2;( *e"bers and %osp!tals apprec!ate t%e use o# PBE+( It"a.es benet a$a!l"ent eas!er #or t%e"(

30( +ast turn-around t!"e ere obser$ed dur!n& t%e

!"ple"entat!on o# ACR, bot% %osp!tals and "e"bers eresat!sed( )%ere !s also decrease !n R)/s cla!"s(

31.So"e o# t%e "e"bers co"pla!n t%at t%ey do not rece!$edt%e!r Benet Pay"ent ot!ce(

32.*e"bers ere d!sappo!nted t%at t%ey cannot #ully ut!l!edt%e!r P%!l/ealt% benets due to t%e #act t%at "ost o# t%e!rsuppl!es or d!a&nost!c procedures needed ere nota$a!lable !n t%e %osp!tal caus!n& out o# t%e poc.ete


5/13


3Q 4Q 1Q 2Q

ot%er cate&or!es(41.A lot o# co""on "ed!cal cases are not !ncluded !n t%e ACR

Pol!cy( *e"bers are re'uest!n& #or t%e !ncrease !n benets

#or so"e %eart related "ed!cal and sur&!cal procedures,oncolo&!c cases and t%e resusc!tat!on pac.a&e( )%erere"a!ns a percept!on t%at benets are less under t%e ACRco"pared !t% t%e ++S(

42( A lot o# %osp!tals !n t%e re&!ons st!ll %a$e no /CI portal!nstalled( )%ere are also reports t%at t%e Portal !s "ostlydon or !naccess!ble due to poor !nternet connect!on,electr!cal !nterrupt!ons, tec%n!cal proble"s, and ot%erune


6/13


3Q 4Q 1Q 2Q

!ealth Care rovider "elations

49( So"e %osp!tals as. "e"bers to s!&n a blan. Cla!"

+or" 2 and so"e e$en #orce "e"bers to s!&n blan.state"ent o# account

46./osp!tal sta are st!ll not updated and not #ully.noled&eable !t% so"e o# t%e ne P%!l/ealt% c!rcularst%us causes proble"6con#us!on on a$a!l"ent(

4:( *ost %osp!tal st!ll separates t%e brea.don o# benets!nto roo" acco""odat!on, dru& and "ed!c!nes etc(

4( /osp!tals are not allo!n& outr!&%t deduct!on o#eborn Care Pac.a&e due to !nco"plete ser$!ces(

4;(So"e %osp!tals per#or"s sur&er!es beyond t%e!r capab!l!ty andalters t%e P%!l/ealt% cla!" to cases co"pensable !n t%e!r

%osp!tal le$el

90( So"e %osp!tals do not pro$!de State"ents o# Account tod!sc%ar&ed pat!ents(

91( /A*A !s not co"pensable to P%!l/ealt% accord!n& toso"e %osp!tal sta(

52.Accred!ted pro#ess!onal #a!ls to !n#or" t%e "e"ber !# t%e!rpro#ess!onal #ee collected to t%e" !s already a net or &rosso# P%!l/ealt%( *e"bers co"pla!n t%at %osp!tals do notpro$!de t%e brea.don o# pro#ess!onal #ees !n t%estate"ent o# account(

93( on-accred!ted doctors attend to P%!l/ealt% "e"bers

%!c% d!s'ual!#y t%e" #ro" a$a!l!n& o# benets( 94( So"e P%!l/ealt% pat!ents ere d!sc%ar&ed !t%out nal

d!a&nos!s on t%e!r c%art %!c% causes proble" dur!n&process!n& o# cla!"s(

55./osp!tal c%ar&es are %!&%er #or P%!l/ealt% *e"bersco"pared to non-"e"bers %!c% o#ten results to e


7/13


3Q 4Q 1Q 2Q

?0( )%e %osp!tal re'u!res CARES to do or. beyond t%e!r@ob descr!pt!on l!.e encod!n& a pat!entGs cla!" or deduct!n&t%e P%!l/ealt% benets o# so"e pat!ents(

?1( /osp!tal per#or"s sur&er!es beyond t%e!r capab!l!ty andalters t%e P%!l/ealt% cla!" to cases co"pensable !n t%e!r%osp!tal le$el(

Issues and Concern4Q#13

1Q#14

2Q#14

oint O$ Care %nrolment62.)%e syste" !s unstable !n so"e %osp!tals( So"e encounter

tec%n!cal proble"s %!c% cause delay !n t%e enroll"ent o#cl!ents( )%ere are also data !ncons!stenc!es beteen t%e 5REsyste" and !CARES(

?3( )%e *ed!cal Soc!al >or.er Ser$!ce s%ould be a$a!lable 246:to enroll pat!ents %o are ad"!tted at n!&%t(

64.Pat!ents %o are enrolled under P5C are not pro$!ded !t%pay"ent sl!p deta!ls and cert!cat!on by t%e *ed!cal Soc!al>or.er Ser$!ce %!c% causes delays !n conne"ent to ot%er%osp!tals(

?9( So"e %osp!tals are !ll!n& to !"ple"ent t%e Pro&ra" but

%a$e bud&et constra!nts(

??( /osp!tal eA coulddeter"!ne !# t%e case o# t%e pat!ent as co"pensable or nott%atGs %y enrol"ent to P5C as delayed(

?:( Pre$!ous /S* pat!ent ere not able to a$a!l o# t%e benets%en ad"!tted to ot%er %osp!tal because t%e P5C %osp!tal ere


8/13

late on t%e!r pay"ent #or t%e sa!d /S*(

?( So"e pat!ents %o are enrolled as /osp!tal Sponsored*e"bers %a$e t%e!r out o# t%e poc.et e


9/13

0( Pat!ents and %ealt% care pro#ess!onals re'uest clar!cat!onabout t%e non-co"pensab!l!ty o# cond!t!ons6nal d!a&nos!s t%at arenot !ncluded !n t%e ACRH part!cularly cases t%at %a$e"an!#estat!ons and cl!n!cal sy"pto"s %!c% su&&est r!&!d "ed!calattent!on and conne"ent(

1( Incons!stenc!es beteen so"e code !n 5/ IC10 cod!n& o#%osp!tal recordsD and codes on P%!l/ealt% anne


10/13

94.Per!toneal !alys!s pat!ents co"pla!n about t%e slo process!n& o#benet re!"burse"ent(

;9( *e"bers ere not sat!sed !t% t%e all case rate becauseaccord!n& to t%e" t%ey are st!ll buy!n& "ed!c!nes and suppl!esouts!de t%e %osp!tal or so"e laborator!es ere una$a!lable(

96./osp!tal cler.s do not depend on t%e "ost resources used !n!dent!#y!n& 1stand 2ndcase rate(

;:( So"et!"es t%ere are d!erences !n IC 10 codes !n anne


11/13

and so"et!"es $!ce $ersa(111( Encountered 5+> "e"bers !t% $al!d $al!d!ty per!od on

ICARES but y!elds a 5 response on PBE+(112( /osp!tals are as.!n& #or a pol!cy t%at !ll apply to pat!ents %o

%a$e %ad PBE+s &enerated but e!ll t%e PBE+re"a!n $al!d a#ter t%e pat!entGs d!sc%ar&e, part!cularly !n !nstances

%ere t%e /CI portal could not be accessed on t%e day o#d!sc%ar&e

11;( /osp!tal re'u!res a lot o# docu"entary re'u!re"ents "arr!a&econtract, B!rt% cert!cate, etc(D %en t%e PBE+ y!elds a 5response( )%e P*R+ s%ould %a$e been su!c!ent to update t%e"e"berGs data(

120( )%ere are %osp!tals %ere only one sta .nos %o to operatet%e /CI portal( In %!s6%er absence t%e *R and C+1 are re'u!red#or sub"!ss!on(

121( )%ere are !nstances %ere t%e PBE+ y!elds a ES upon

ad"!ss!on t%en y!elds a 5 at t%e t!"e o# d!sc%ar&e(

122( )%ere are %osp!tals t%at st!ll re'u!res t%e sub"!ss!on o# *Rand ot%er docu"ents e$en !# t%e PBE+ y!elds a ES(

123( So"e %osp!tal donGt allo t%e use o# PBE+ on d!alys!s sess!onsand re'u!re t%e old set o# re'u!re"ent(

124( )%ere are reported cases %ere t%e dependent !s declared !nt%e !CARES and *R but t%e PBE+ y!elds a 5 !t% anundeclared dependent re"ar.(


12/13

129( PBE+ ansers ES e$en t%ou&% t%e dependent declared !n I-CARES as !n$al!d(

12?( )%ere are !nstances %ere t%e syste" does not y!eld a ES or5 response(

12:( St!ll a lot o# %osp!tals !n t%e re&!ons %a$e no /CI portal

!nstalled(

12( )%e /CI portal !s "ostly don or !naccess!ble( It !s also nota$a!lable 246: !n so"e %osp!tals and on ee.ends(

129. )%ere are 5+> "e"bers !t% a posted contr!but!ons !n t%e !-CARES and *R but y!elds a 5G response !n t%e PBE+ !t% aproo# o# contr!but!on re'u!red re"ar.(

130( PBE+ does not detect !# dependents are declared by ot%er"e"bers or %as t%e!r on PI(

131( So"e %osp!tal only pr!nt PBE+ !# !t y!elds a ES response onel!&!b!l!ty and !# y!elds a 5 response t%ey @ust re'u!re t%e"e"ber t%e bas!c re'u!re"ents on benet a$a!l"ent(

132( /osp!tal as not us!n& PBE+ cons!stently(

Issues and Concern

(!)*+"/4s

133. It !s %ard to d!erent!ate beteen /)S-PR and 7= Sponsored*e"bers us!n& t%e !CARES(

134. Fal!d!ty dates o# !nd!&ent and sponsored "e"bers are not re8ected !nt%e !CARES syste"( /)S-PR67= sponsored "e"bers %ose"e"bers%!p !t% un-updated "e"bers%!p $al!d!ty are re'u!red to &o tot%e 7/I5 to secure a CE1 +or"(

139( *R o# Ind!&ent "e"bers %as st!ll a lot o# d!screpanc!es( *ost o#t%e" cannot pro$!de support!n& docu"ents to correct t%osed!screpanc!es %!c% leads to non-a$a!l"ent(

136. A lot o# 4Ps !nd!$!duals are not re&!stered !t% P%!l/ealt%(137. A lot o# 4Ps and !nd!&ent "e"bers %a$e dual PIs or ot%er

"e"bers%!p cate&or!es(13( CARES obser$ed t%at t%ere ere st!ll 4Ps Is %!c% ere not $al!d as per

t%e c!rcular 24s( 2012(

139.BB ent!tled 4Ps !ncur out-o#-poc.et e


13/13

143. So"e 4Ps "e"bers only %a$e cert!cat!ons %!c% !s not $al!d #orbenet a$a!l"ent(

144( All 4Ps "e"bers are $er!ed rst to S> be#ore a$a!l!n& o# benets%!c% causes delay s!nce e %a$e no d!rect access or contact person onS>(

149( St!ll a lot !nd!&ent "e"bers %a$e no or so"et!"es !n$al!d $al!d!typer!od posted !n t%e !-CARES syste"(

146. So"e pat!ents use #a.e 4Ps I and Jasunduan Cert!cateD( So"e%a$e no records !t% t%e S>(

147. !str!but!on and screen!n& o# !nd!&ent6sponsored "e"bers be!n&'uest!oned by /osp!tals( +a"!l!es !n &reat need o# %elp and %a$e no"eans to pay are re"o$ed #ro" t%e pro&ra" %!le so"e %o a #a"!ly"e"ber or.!n& abroad or e$!dently %as t%e capac!ty to pay are &!$enco$era&e(

148. )%ere ere !nd!&ent "e"bers %o already deceased #or a lon& t!"ebut st!ll %a$e act!$e "e"bers%!p(

14;( )%ere ere st!ll a lot o# d!screpanc!es on t%e data o# t%e "e"ber andt%e!r dependents on t%e P%!l/ealt% database(

150. 4Ps "e"bers !ns!st on us!n& t%e 4Ps Is o$er t%e yello *R orP%!l/ealt% Cards on t%e assu"pt!on t%at t%ey !ll not be re'u!red to payanyt%!n& !# t%ey use t%e #or"er

191( )%ere are 4PS "e"ber %oGs us!n& ot%er peopleGs !dent!ty( )%ey call !t asKA*PAK %!c% "eans t%ey ta.e o$er t%e !dent!ty o# t%e person !n I to use!ts benets(

192( So"e "e"bers o# t%e /)S are act!$ely or.!n& abroad andcurrently e"ployed(

193( *R ere not &!$en to t%e /)S-PR "e"bers but be!n& %old on t%e

Rural /ealt% =n!t(154.4PGs "e"ber %o use t%e #a"!ly na"e o# %er l!$e-!n partner cla!"!n&

t%at t%ey are "arr!ed aects t%e!r el!&!b!l!ty( S> ad$!sed t%e" to uset%e last na"e o# t%e l!$e-!n partner %!c% !s not supposed to be usedcons!der!n& t%at t%ere are no le&al papers to support suc% ob@ect(

199( Ind!&ent "e"bers %a$e no !dea about t%e o Balance B!ll!n& Pol!cy(

Consolidated b,-

LLLLLLLLLLLLLLLLLR!c%ard P( Sons!n&P*)-CARES

3rrdd quarter

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