Download - 3rrdd Quarter
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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$e PI(
:( )%ere ere so"e P%!l/ealt% "e"bers report!n& t%at so"eo# t%e!r declared dependents ere o"!tted !n t%e!r *R,t%ose dependents are t%ose !t% %!story o# benet
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Issues and Concern2013 2014
3Q 4Q 1Q 2Q
a$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$ed espec!ally pre&nant o"en(
15.*e"bers ere unaare t%at t%ere are P%!l/ealt% E
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7/25/2019 3rrdd Quarter
3/13
Issues and Concern2013 2014
3Q 4Q 1Q 2Q
19.*e"bers are d!sappo!nted because o# t%e late post!n& o#t%e!r contr!but!ons pa!d t%ru t%e ACAs( Also, o!c!alrece!pts !ssued by ban.s6ACAs to t%e "e"bers do not
re8ect "ont%s and 'uarter pa!d or %a$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
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Issues and Concern2013 2014
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
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7/25/2019 3rrdd Quarter
5/13
Issues and Concern2013 2014
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$e no /CI portal!nstalled( )%ere are also reports t%at t%e Portal !s "ostlydon or !naccess!ble due to poor !nternet connect!on,electr!cal !nterrupt!ons, tec%n!cal proble"s, and ot%erune
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Issues and Concern2013 2014
3Q 4Q 1Q 2Q
!ealth Care rovider "elations
49( So"e %osp!tals as. "e"bers to s!&n a blan. Cla!"
+or" 2 and so"e e$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
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7/25/2019 3rrdd Quarter
7/13
Issues and Concern2013 2014
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$a!l o# t%e benets%en ad"!tted to ot%er %osp!tal because t%e P5C %osp!tal ere
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7/25/2019 3rrdd Quarter
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late on t%e!r pay"ent #or t%e sa!d /S*(
?( So"e pat!ents %o are enrolled as /osp!tal Sponsored*e"bers %a$e t%e!r out o# t%e poc.et e
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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$e"an!#estat!ons and cl!n!cal sy"pto"s %!c% su&&est r!&!d "ed!calattent!on and conne"ent(
1( Incons!stenc!es beteen so"e code !n 5/ IC10 cod!n& o#%osp!tal recordsD and codes on P%!l/ealt% anne
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7/25/2019 3rrdd Quarter
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94.Per!toneal !alys!s pat!ents co"pla!n about t%e slo process!n& o#benet re!"burse"ent(
;9( *e"bers ere not sat!sed !t% t%e all case rate becauseaccord!n& to t%e" t%ey are st!ll buy!n& "ed!c!nes and suppl!esouts!de t%e %osp!tal or so"e laborator!es ere una$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
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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$en !# t%e PBE+ y!elds a ES(
123( So"e %osp!tal donGt allo t%e use o# PBE+ on d!alys!s sess!onsand re'u!re t%e old set o# re'u!re"ent(
124( )%ere are reported cases %ere t%e dependent !s declared !nt%e !CARES and *R but t%e PBE+ y!elds a 5 !t% anundeclared dependent re"ar.(
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129( PBE+ ansers ES e$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 $al!d as per
t%e c!rcular 24s( 2012(
139.BB ent!tled 4Ps !ncur out-o#-poc.et e
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143. So"e 4Ps "e"bers only %a$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