Transcript Beach 10 - Official Philippine Neurological Association

PhilHealth
Claims Filing
Reducing Mistakes,
Increasing Reimbursements
Know the Rules!
• PhilHealth does not pay for all your
health care costs.
• PhilHealth pays only for covered items
and services when its rules are met.
• Members usually give a co-payment for
the portion of the actual cost that is not
covered by PhilHealth
PhilHealth
• Govt owned and controlled corporation
• Created by Republic Act 7875
• National Health Insurance Program
(NHIP)
• Amended by Republic Act 9241
• Access to health care is a basic right of
citizens
– “Universal coverage”
Members
and
Dependents
Our Members
1. Employees (govt and private)
– monthly payment (3% salary)
2. Individually Paying Program (voluntary)
- quarterly payment (1,200/year)
3. Overseas Workers Program
- Annual payment (900/year)
Our Members
4. Non-paying (pensioner)
- no payment for life
• 60 years old
• With total 120 monthly contributions
5. Sponsored (thru partnership with LGUs)
- annual payment, eligibility for 1 year
Your Dependents
• Spouse
• Children < 21 years old
• Parents > 60 years old
–Step parents
–Adoptive parents
Benefits
45 Days Annual Allowance
• 45 days allowance per year for the
principal (member)
• Another 45 days shared among
dependents
Your benefits
• Illness requiring hospitalisation
• Outpatient:
– Surgical procedures
• Cataract surgery
• BTL
• Vasectomy
• Endoscopy
• Excision
• Suturing
Drugs and Medicines
• Only drugs used during confinement will be
paid
• Drugs must be written in generic name
• Closed formulary – only drugs listed in the
preferred list* will be covered by PhilHealth
*6th edition of the Philippine National Drug
Formulary (PNDF)
Anti-convulsants /
Epileptics
– CARBAMAZEPINE
– CLONAZEPAM
– DIAZEPAM
– LORAZEPAM
– MAGNESIUM
SULFATE
– PHENOBARBITAL
– PHENYTOIN
– VALPROIC DISODIUM
–Gabapentin
–Midazolam
–Thiopental
sodium
–Topimarate
Anti-Parkinsonism
– LEVODOPA +
BENSERAZIDE
• 100 mg/25 mg
• 200 mg/50 mg
– LEVODOPA +
CARBIDOPA
• 100 mg/25 mg
• 250 mg/25 mg
–Pirebidil
• 50 mg
–Selegiline
• 5 mg
Case: 65 years old
Diagnosis: Parkinson’s Disease
Drugs:  Levodopa + Benserazide # 60
 Nifedipine 30 mg # 60 (PNDF)
 Telmisartan tab # 60 (non-
PNDF)
Admission: September 17 - 20
What drugs will be paid?
Case:
Diagnosis: Parkinson’s Disease, HPN
Drugs:  Levodopa + Benserazide # 60
Nifedipine 30 mg # 60
 Telmisartan tab # 60
Admission: September 17 - 20
How many will be paid?


Drugs and Medicines
• Only drugs, supplies, and lab
used on confinement shall be
paid
– Must be supported by official
receipts
Fee for Service Scheme:
• physician charges separately for each
patient encounter or service rendered
• expenditures increase if more services
are provided or a more expensive
service is substituted for a less
expensive one
• Needs itemization
Computation of Benefits
• Case type of illness
• Category of Facility
Casetypes
•
•
•
•
Casetype A – Ordinary
Casetype B – Intensive
Casetype C – Catastrophic
Casetype D – Super Catastrophic
Level 3 & 4 Hospitals (Tertiary)
Case-type
A
B
C
D
Room & Board*
P400/day
P400/day
P400/day
P1,035/day
Drugs and Medicines**
P3,000
P9,000
P16,000
P35,635
X-ray, Lab & Others**
P1,700
P4,000
P14,000
P29,430
Operating Room**
RVU 30 and below =
P1,060
RVU 31 to 80 = P1,350
RVU 81 up to 200 =
P3,490
RVU 201 up to 500 =
P3,490
RVU > 500 =
P10,470
Level 2 Hospital (Secondary)
Room & Board*
P300/day
P300/day
P300/day
P660/day
Drugs and Medicines**
P1,700
P4,000
P8,000
P19,725
X-ray, Lab & Others**
P850
P2,000
P4,000
P10,215
Operating Room**
RVU 30 and below =
670
RVU 31 to 80 = P1,140
RVU 81 up to 200 =
P2,160
RVU 201 up to 500 =
P2,160
RVU > 500 =
P6,480
Level 1 Hospital (Primary)
Room & Board*
P200/day
P200/day
N/A
N/A
Drugs and Medicines**
P1,500
P2,500
N/A
N/A
X-ray, Lab & Others**
P350
P700
N/A
N/A
Operating Room**
RVU 30 and below =
P385
N/A
N/A
N/A
* Not exceeding 45 days for each member & another 45 days to be shared by his/her dependents
** Per single period of confinement
Benefit Periods
• PhilHealth benefits are divided into
benefit periods
• A benefit period is essentially a single
hospital stay, including re-hospitalisation
of up to 90 days
• In each benefit period, PhilHealth will
only pay 1 benefit
Single Period of Confinement
• Example
– a 3 week chemotherapy cycle,
where a patient has treatment on
the 1st and 8th days, but nothing
on days 2 - 7 and days 9 - 21
– Medicine per session is 5,000
Benefit
Unused
Payment
16,000
January 1
16,000
5,000
January 8
11,000
5,000
January 22
6,000
5,000
January 29
1,000
1,000
February 12, 19,
0
0
90 days after
January 1
New 16,000
March 5
16,000
5,000
March 12
11,000
5,000
March 1
Single Period of Confinement
• You may only avail of the unused
benefits except:
– for room and board fees
– Professional fees
 until the 45 day allowance is fully
exhausted.
Professional
Fee
Professional Fees**
Case-type
General Practitioner
Specialist
A
B
C
D
P150/day not
exceeding P600
P150/day not
exceeding P900
P150/day not
exceeding P900
P315/day not
exceeding
P2,430
P250/day not
exceeding P1,000
P250/day not
exceeding P1,500
P250/day not
exceeding P2,500
P450/day not
exceeding
P4,050
Surgeon
(P40/RVU) not exceeding P16,000
(P120 /RVU for
consultation) but not
exceeding P47,790
Anesthesiologist
** Per single period of confinement
30% Surgeon’s fee not exceeding P5,000
30% Surgeon’s fee
not exceeding
P14,355
Professional Fee
• based on the Relative Value Units (RVU)
• The RVU must be multiplied by a Peso
Conversion Factor (PCF) to become a
payment schedule
• Surgeons: RVU x P 40
• Covers preoperative visits, intraoperative
services, postoperative services for 90
days
• Anesthesiologist: (RVU x P 40) x 30%
Professional Fee
Example:
66270
Spinal puncture
12 RVU x 40 PCF = Php 480
12
Professional Fee
Example:
61793 Stereotactic radiosurgery
200
200 RVU x 40 PCF = Php 8,000
Professional Fee
Example:
61500 Craniectomy w/ excision of tumor
400
400 RVU x 40 PCF = Php 16,000
Policies on PF
• > 2 procedures, single opening
= pay highest value
•
> 2 procedures, different incision site
= pay all unit values
•
Procedures done on different dates
= pay all unit values
Policies on PF
Example:
49000
44950
-
Explor Lap
Appendectomy
-
150 RVU x 40 PCF = P6,000
150
100
Policies on PF
Example:
49000 - Explor Lap
58943 - Oophorectomy for
ovarian CA
200 RVU x 40 PCF = P8,000
- 150
- 200
Policies on PF
Example: Bilateral Cataract Extraction
69887 - ECCE phacoemulsification - 200
200 x 2 = 400 RVU
400 RVU x 40 PCF = P16,000
Policies on PF
Repeat Procedures:
• Payment within cap
• Covered by rule on single period of
confinement
Service Rendered
Computed Benefit PHIC Benefit
Ligation, varices esophagus
10,000
10,000
Ligation, varices esophagus
10,000
6,000
Total = 16,000
Professional Fee
Example:
66270
Spinal puncture
12 RVU x 40 PCF = Php 480
12
Professional Data & Charges
PART II - PROFESSIONAL DATA AND CHARGES ( Doctor/s to Fill in Respective Portions )
14. Complete Final Diagnosis
15. Case Type
Ordinary
FOR PHILHEALTH USE
Intensive
16. Name of Attending Physician

Relative Unit Value
Catastrophic
Signature & Date Signed
17.PHIC Accreditation No.
18. BIR/TIN No.
19. Services Performed
20.
-
P
P
22.PHIC Accreditation No.
23. BIR/TIN No.
24. Services Performed
25.
Date of Operation
Reduction Code
-
Benefit Claim
Surgeon
Patient
Actual
P
P
Signature & Date Signed
26. Name of Anesthesiologist
27.PHIC Accreditation No.
28. BIR/TIN No.
29. Services Performed
30.
Anesth
-
Professional Charges
P
-
Reduction Code
-
Benefit Claim
Physician
Patient
Actual
Professional Charges
P
Reduction Code
P
Signature & Date Signed
21. Name of Surgeon
RVU
-
Benefit Claim
Physician
Patient
Actual
Professional Charges
Daily visit
Illness Code
P
P
Professional Data & Charges
With deduction
Signature & Date Signed
21. Name of Surgeon
22.PHIC Accreditation No.
23. BIR/TIN No.
24. Services Performed
25.
Lumbar tap
Date of Operation
-
1000
-
Benefit Claim
Surgeon
Patient
Actual
Professional Charges
P
Reduction Code
P
480
P
520
Professional Data & Charges
With no deduction
Signature & Date Signed
21. Name of Surgeon
22.PHIC Accreditation No.
23. BIR/TIN No.
24. Services Performed
25.
Lumbar tap
Date of Operation
-
1000
-
Benefit Claim
Surgeon
Patient
Actual
Professional Charges
P
Reduction Code
P
P
1000
Professional Data & Charges
Complimentary PF; PhilHealth only
Signature & Date Signed
21. Name of Surgeon
22.PHIC Accreditation No.
23. BIR/TIN No.
24. Services Performed
25.
Lumbar tap
Date of Operation
-
480
-
Benefit Claim
Surgeon
Patient
Actual
Professional Charges
P
Reduction Code
P
Actual PF = PhilHealth benefit
480
P
Professional Data & Charges
Government hospital; Private Patient
Private hospital; Service Patient
Signature & Date Signed
21. Name of Surgeon
22.PHIC Accreditation No.
23. BIR/TIN No.
24. Services Performed
25.
Dialysis
Date of Operation
-
400
-
Benefit Claim
Surgeon
Patient
Actual
Professional Charges
P
Reduction Code
P
400
P
Private Patient, Government Hospital
PAY TO DOCTOR
NO Stamp: PF is made to the Chief
Service Patient, Pay Hospital
Name of Surgeon
PAY TO CHIEF
NO Stamp: PF is made to the MD who
signed Form 2
Eligibility Rules
Are you eligible?
• For employed and IPP, at least 3 monthly
contributions within the immediate 6
months prior to admission
• the 45-days allowance for room and board
has not been consumed yet
• confinement in an accredited hospital of
not less than 24 hours
Case
• Employed member since January 2006
• Admitted for Myelography for tumor (?)
• Paid premium up to January to March
2007
• Is Aug
the claim
compensable?
Jul
Sep Oct
Nov Dec Jan Feb Mar
x
6
5
X – start of membership
4
3


2
1
No !
Admit

Apr
Yes !
Case
• IPP applied membership March 2007
• Premium paid
• Admitted April 2007 for TIA
Jul
Aug Sep
Oct
6
Nov Dec
5
X – start of membership
4
Jan
Feb Mar
x

 
3
2
1st quarter
1
Apr
Admit
06/08/2007
300
2007 P 300
300
•
What if a member enroll today, when can he
start availing PhilHealth benefits?
Adverse selection
•
•
•
•
•
Phenomenon whereby a disproportionate
share unhealthy individuals (high risk)
enroll in a health plan
Hidden information; member moral
hazard
Influenced by benefit design and
individual decision
In contrast to guiding principles of
social solidarity
Example: CS, Cataract
Circular 36 s. 2006
For IPP, at least 9 monthly contributions
within the immediate 12 months prior to
admission for the following:
1.
2.
3.
4.
Hemodialysis and Peritoneal Dialysis
Chemotherapy
Radiation oncology
Selected surgeries:
• CS
• D&C
• Cataract
• Endoscopy
effective April 1, 2007
Supplier induced demand
• Demand created by doctors beyond
what would have occurred in a
market
• Influenced by benefit design and
individual decision
• Hidden action
• Doctor moral hazard
PhilHealth Payment 2004
Cataract (69887 & 66984)
• Total Payment:
590 million
• Total Number Claimed: 28,997
• AVPC:
• Average PF:
20,368.83
7,700
Adverts
• False adverts tends to deceive or
mislead the public which makes an
untruthful assertion
– E.g., “Free cataract surgery for
PhilHealth members “
– “No out of pocket payments for
PhilHealth members”
Adverts
• Cataract surgery announced as free
should not be filed to PhilHealth and
be offered to all regardless of
PhilHealth membership status
– Why not offer it to all?
– Not free; PhilHealth as third party payor
Solicitation of patients
• Solicitation of patients, directly or
indirectly, through solicitors or
agents, is unethical
– Example:
• NGO sponsorship of medical mission
• Doctors paying for patients premium
– 300 pesos versus 49,000 pesos (bilateral
ECCE)
RVS 2001
• Historically-abused procedures
– Utilization trend data
– Institutional memories
• Blepharoplasty
• Removal of FB, eye
• Pterygium
–Excision (20)
Conjunctivoplasty (60)
RVS 2001
Upcoding or Creeping:
• In claims submission, using a higher level
procedure code than the level of service
actually provided
• E.g., appendectomy (100 RVU) to
AP ruptured (150 RVU)
ICD-10
ICD-10
• An international
classification designed
to enable
CONSISTENCY of
coding THROUGHOUT
the world.
STRUCTURE OF ICD-10 CODE:
 The structure of the 4-character category is:
Lastly
Another
digit
First character
A to Z
(Except U)
Followed
by
2 digits
then
a point
MAIN ELEMENTS TO THE
STRUCTURE OF ICD-10
 There are three (3) volumes
 There are twenty one (21) chapters
 The structure of the code is alphanumeric
VOLUMES OF THE ICD-10:
 Volume 1 (Tabular List) – alphanumeric listing of
diseases and disease groups
 Volume 2 - contains instructions and guidelines for
Mortality and Morbidity coding
 Volume 3 (Alphabetical Index) – comprehensive listing
of all the conditions in the Tabular List
Basic Coding Guidelines
Follow carefully any cross-references
found in the index.
Refer to the Tabular List (Vol. 1)
Be guided by any inclusion and
exclusion terms under the selected
code, chapter, block or category
heading.
Finally, ASSIGN THE CODE.
Example:
Assign the ICD-10 code for
Chronic viral hepatitis C
Answer: Lead term:
Hepatitis
-viral
--chronic
---type
----C B18.2

PhilHealth Circular Number 27
series of 2003
“ All claims with no ICD-10 codes,
incorrect codes/and or
ambiguous ICD-10 codes shall
NO LONGER BE DENIED but
shall be returned to the
accredited health care provider
(RTH) on the ground of noncompliance with the correct ICD10 codes ”
Nervous System
 Categories ranged from G00-G99
 67 of the 100 available categories have been used
 There are 11 blocks within this Chapter.
 There are 16 asterisk categories. Most of them are result of infectious
conditions, as well as neurological conditions resulting from other diseases
and conditions
 G00-G09 block classifies diseases where the nerve tissue
is attacked by various organisms
Nervous System
 Meningitis is usually due to infection and is classified by a
combination of a dagger code for Chapter 1 and an asterisk code from
G01 or G02 to provide more information
 G09(Sequelae of inflammatory diseases of central nervous system)
would be listed as a secondary code with the sequelae itself being listed
as the main condition
 It should be noted that seizures and convulsions NOS are
coded R56.8 and are not considered epilepsy unless the
term “epilepsy” is specifically used
ICD-10
G45.9
G45.0
: TIA (O)
: vertebrobasilar insufficiency (O)
I67.9
: CVA, unspecified (C)
I66.9
I61.9
I63.9
: CVA, cardioembolic (D)
: CVA, hemorrhagic (D)
: CVA, thrombotic infarct (D)
MORPHOLOGY OF NEOPLASMS:
 The classification of morphology of neoplasms
(pp. 1177-1204) is used as an additional code to
classify the morphological type for neoplasms
S
Site
C00 - D48
M
Morphology
M8000 – M9989
B
Behavior
/0, /1, /2, /3, /6
ICD-10
C71.9, M9400/3
• Neoplasm of brain
• Astrocytoma
• Malignant
ICD-10
D32.1, M9530/0
• Neoplasm of spinal meninges
• Meningioma NOS
• Benign
ICD-10
C50.9, M8010/3
C71.2, M8010/6
1. Breast carcinoma, primary
2. Metastatic carcinoma, temporal
lobe
Additional Tips for Better Payment
1. Eliminate down coding by providing complete
descriptions
2. Rank procedures by order of importance
3. Don’t send documents not required
4. Submit claims promptly and frequently
5. Complete forms ASAP
6. Fill in all blanks. Type NA
7. Make it a practice to follow up with Claims Dept.
ICD-10
G96.1 : Disorders of meninges, unspecified (B)
G00.9 : Bacterial meningitis (C)
G04.2 : bacterial meningo-encephalitis (D)
Updates
Circular 11, 2007
Code
Descriptive Terms
RVU
99256
Inpatient consultation for a new or
established patient which requires: an
expanded focused history,
examination and medical decision
making. It is requested by another
physician or appropriate source; the
consultant advises the requesting
physician about the management of a
specific problem including follow up
care for 90 days after the procedure
40
Circular 11, 2007
– Preoperative medical evaluation is a
service provided by a physician whose
opinion or advice is requested by
another physician regarding evaluation
and/or management of a specific
medical problem which might affect the
patient’s ability to undergo a procedure
or might influence the outcome of the
procedure
Circular 11, 2007
• Qualified physicians who can claim
for this service:
– Family medicine
– Internal Medicine
– Neurology
– Pediatrics
Circular 11, 2007
• Applicable only while the patient is
admitted
• Preoperative medical evaluation
given on an outpatient basis will not
be compensated
Circular 11, 2007
• Service is applicable only if surgery is
accomplished within the same
admission period.
– If surgery is deferred  no payment
• But may claim PF based on daily
visits subject to allowable amount per
hospital admission
Circular 11, 2007
• In filing for claims, a copy of the
consultation/clearance form with the
corresponding assessment and
recommendation must be attached
Contact Us:
www.philhealth.gov.ph
[email protected]
0918-9001618