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Ian Alfredo Magno

PRIOR hereto, “length of stay” (LOS) – or the minimum number of days a patient stays in the hospital from confinement to discharge date – was required in certain illnesses, as a condition for medical reimbursement under Philhealth.  For instance, for acute gastro entiritis (AGE), also known as diarrhea – three days; for urinary tract infection (UTI) – four days; and for pneumonia – four days.  Otherwise, hospitalization expenses incurred via confinement under the foregoing diagnoses would not have been reimbursed.

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Under the all case rate payment scheme, the package rate for AGE is P6,000; UTI ranges from P6,900 to P12,700; P15,000 for moderate risk pneumonia, and P32,000 for highisk pneumonia.

As of Sept. 25, 2017, however, Philhealth Circular No. 2017-0028 was signed, taking effect 15 days after its publication.  Particularly, such issuance eradicated the hospitalization “length of stay” requirement as a condition for reimbursement particularly involving the above-mentioned illnesses.  In lieu thereof, a pre-payment medical review shall instead be done to assess their compensability, on a case-to-case basis.

Part V of PC No. 2017-0028 sets the general guidelines therefore, to wit:

  1. a) “The LOS shall not be the basis for claims reimbursement of pneumonia, acute gastroenteritis and urinary tract infections. Claims for confinements that fall below the recommended LOS shall not be denied.
  2. b) All claims application for pneumonia, acute gastroenteritis and urinary tract infection and sepsis shall require submission of their corresponding certified true copy of complete clinical chart of the patients which details the history of present illness, course in the ward, vital signs monitoring, doctor’s order sheet, nurse’s notes, laboratory and imaging results, among others.
  3. c) Claims application without the required attachment of certified true copy of patient clinical charts shall be returned to sender (RTS).
  4. d) For all other conditions, clinical charts and other related documents shall be made available upon request by the corporation.
  5. e) The corporation reserves the right to subject any and/or all claims application for pneumonia, acute gastroenteritis and urinary tract infection to pre-payment medical review.
  6. f) Applications of existing policies shall apply during pre-payment medical review. Any violation of the policies of the corporation shall cause the denial of the claim.
  7. g) Philhealth may subject other conditions or surgical procedures to prepayment medical review and submission of complete clinical charts or other documents as deemed necessary thru the issuance of an advisory anchored on this circular.”

Ultimately, the paramount objective of this recently issued circular is to address the moral hazards and other violations vis-à-vis the performance commitment of concerned health care providers.

 

(Ian Alfredo T. Magno is a practicing lawyer based in Cagayan de Oro and a legal officer at Philhealth. E-mail: ianalfredom@gmail.com)

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