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PhilHealth clarifies ‘suspicious PhilHealth episodes’

05:01 AM July 02, 2019

This is in reaction to the letter “Suspicious PhilHealth episodes” (6/21/19) from Oscar P. Lagman Jr.

We wish to clarify some points raised by Mr. Lagman:

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On doctors’ professional fees

Please be informed that inpatient benefits are paid to the accredited health care institution (HCI) or hospital through All Case Rates or package rates payment mechanism. The case rate amount shall be deducted by the HCI from the member’s total bill, which includes the professional fees of attending physicians prior to discharge.

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PhilHealth employees in a hospital

As regards your statement that Philippine Health Insurance Corp. (PhilHealth) people in a hospital are filing claims for doctor’s fee, may we clarify that those assigned at the billing/PhilHealth section of the hospital are not employees of PhilHealth, but hospital employees. The only PhilHealth employees assigned to the hospital are PhilHealth customer assistance relations and empowerment staff (PCARES). PCARES are registered nurses who are trained to provide assistance to our members and ensure the outright availment of PhilHealth benefits. They are not allowed to process a claim or accept premium payments. PCARES desks are open from Mondays to Fridays at 9 a.m. to 5 p.m.

Denied claim for dental surgery performed in a dental clinic

PhilHealth covers dental surgeries or minor sutures done by an accredited dentist in an accredited clinic or hospital. If the procedure is done in a nonaccredited clinic even if it is located inside the accredited hospital, the claim may also be denied due to lack of accreditation requirements. The dentist who performed the dental surgeries or minor sutures cannot claim for professional fee if he is also not accredited.

Benefit claim for open heart surgery or coronary artery bypass graft (CABG)

PhilHealth Z Benefit for CABG has a case rate or package amount of P550,000. This covers payment for hospital services such as hospital room and board fees, drugs and laboratory exams, operating room and professional fees for the entire course of treatment, including mandatory and other services required per illness. Aside from this package, a 20-percent discount is also deducted if the patient happens to be a senior citizen. This is on top of PhilHealth deductions from the hospital bill.

DR. SHIRLEY B. DOMINGO
Vice President for Corporate Affairs
Philippine Health Insurance Corp.

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