Download - 20131126 RIC October AR Report A
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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