De Guzman-Magno, L. (2018). Philhealth all case rates benefits: Misused and abused? (Unpublished master's thesis). Public Management Development Program, Development Academy of the Philippines.

Public Management and Development Program Senior Executive Class Batch 6 Thesis (SEC)--Development Academy of the Philippines.

When Juan de la Cruz falls ill and has to be hospitalized, the expense incurred usually pose problem to his family. But the problem is somehow eased because PhilHealth exists, and it is there to help. PhilHealth provides solution but people probably do not know that it is faced with formidable problems of its own. Indeed, PhilHealth now faces difficulties, problems and issues. These are related to the current payment scheme used in the reimbursement of claims files by accredited facilities. This paper will focus of the claims files by and paid to accredited hospitals and infirmaries, providing as an example a level 1 hospital in Pampanga where PhilHealth has detected certain issues that must be resolved. Apparently, the effectiveness of the corporation in implementing the current All Case Rates benefit payment scheme shifting from the Fee-for-Service payment are not realized. On the contrary, PhilHealth faces more difficulties and problems with the implementation of the ACRs. Significant amount of payment has been paid and is still being paid to these health care facilities, but there is reason to suspect that some claim are dubious. For this capstone paper, only the top fve medical conditions and benefit payments thereof were filtered and presented. These illness are: Illness Benefit Payment Pneumonia (Moderate-Risk) P 15,000 Pneumonia (High-Risk) P 32,000 Acute Gastroenteritis P6,000 Urinary Tract Infection P 7,500 Dengue I P 10,000 Bronchial Asthma P 9,000 The increase in the number of claims submitted and the number of claims paid was consistently observed among these top illnesses. Although the number of certain diseases decreased in certain years, still, the amount paid totaled up to billions of pesos. All of the five illnesses reached the billion mark payment in 2016. Let us not forget that these are just top five most claimed and paid medical illnesses in the Philippines. There are many more medical illnesses for which claims for reimbursement were filed, and which PhilHealth reimbursed with much higher benefit payments when combined. And there are also procedural or surgical cases that in all probability might also have registered significant increases, there are suspicions of misuse, abuse of the All Case Rates and possibly fraud. The trends in the submission of reimbursement claims of hospitals change especially for pneumonia, the number one illness reported to PhilHealth claiming benefit payment. PhilHealth Circular No.31 series 2014- Health Care Provider Performance Assessment System (HCP PAS) was implemented to monitor access to PhilHealth benefits, provision of quality care and protection to all members (PhilHealth, 2014). However, accredited health care facilities were not monitored regularly as planned and desired. Facilities found to be remiss based on monitoring and which have become subject of complaints should have been mandatorily checked but they were only visited periodically or depending upon the gravity of the findings and offenses committed. This was because no official office/ section or monitoring unit in regional offices was created solely for this demanding function. Instead, selected staff coming from different offices were tasked to do the monitoring, consolidation of reports and submission to concerned offices. Mush as PhilHealth regional offices would like to perform this function added to their inherent tasks, the voluminous work load in their mother offices did not allow them to. In August 2016, the initial HCP PAS circular was revised and was implemented as PhilHealth Circular No. 26 series 2016 - Health Care Provider Performance Assessment System (HCP PAS) Revision 1. The policy sought to establish guidelines to monitor access to PhilHealth benefits, provision of quality health care, and assurance of financial risk protection to all members (Philhealth, 2016). It likewise established procedures in the submission of standardized reports called the Provider Performance Monitoring Report (PPMR) by all regional offices. For instance, all regional offices are required to submit monthly PPMR on facilities with so-called red flags and monitoring findings. The reports are forwarded to the Standards and Monitoring Division (SMD) and findings are also submitted to the Legal Services Units (LSU) of all regional offices for validation and appropriate actions. However, the inadequate staff/ personnel of the LSUs as well as the increasing number of facilities with findings makes it difficult for them to conduct the validation visits. In Philhealth Regional Office III (PRO III), the PCares or Philhealth Customer Assistance Relations and Empowerment Staff, the PhilHealth nurses assigned at selected hospitals to assist members and non-members in the availment of hospitalization benefits, help also in monitoring the facilities where they are assigned. Their findings are forwarded to regional offices for appropriate actions. Numerous violations, as well as complaints of members are now being monitored and reported. These violations included the following 1.) Refusal of provision or non-provision of PhilHealth benefits to qualified member 2.) Underutilization of benefits 3.) Upeasing or upgrading of illnesses 4.) "Sweeping" of patients especially cataract and hypertension cases 5.) Non-deduction of professional fees 6.) Procedure creeping 7.) Filing of claims for patients who were not treated nor admitted found during monitoring 8.) Signing of professionals/ doctors for procedures they did not perform, and other offenses not related to ACRs. During the regional consultative meeting of PhilHealth in Cagayan de Oror in April 2017 these issues and problems were tackled and immediate and long-term solutions were proposed. At PhilHealth Regional Office III, the management is implementing strategies and ways to solve the problems. These show the efforts and determination of management to address and solve these problems seriously. We at PhilHealth may not as yet have the exact answers, explanations, clarifications or solutions to all of these problems but we are getting there. Hopefully, this paper could provide inputs in the reach for solutions.