Issues and Concerns Reported by CARES

October, 2013
Below is an enumeration of important issues and concerns observed by the
CARES deployed in accredited hospitals during October of 2013. This list is
based on submitted reports collated by the PMT-CARES.
Membership
1. Retirees who are able to complete 120 months of contribution are not
aware that they can apply to PhilHealth for Lifetime membership
2. 4Ps members allow their relatives to use their own PhilHealth since the
ID has no picture.
3. Sponsored Members complain of the wrong information encoded in their
PVC ID they received causing problems during benefit availment
4. Employers data, such as PEN and Employers Name, of some employees
have not yet been updated in our database.
5. I-Group Members are unaware that their PhilHealth membership has a
validity period.
6. Mismatch data on Member Data Record and PhilHealth ID of members
7. LHIOs are very strict in scrutinizing the supporting documents submitted
by members especially those under the Sponsored/Indigent Program.
8. Expand the PhilHealth Express program not only in malls but to other
cities and municipalities that have health care facilities so that
PhilHealth is accessible to all; especially in catering to the membership
concerns, enrolment and queries about benefits availment.
Contributions
9. Members under the Informal Economy are having difficulty in making
their premium payments due to lack of available and accessible payment
centers in the area.
10. In some ACAs, details on the PAR are not printed clearly or easily
fades off.
SM Bayad Center Puerto Galera Branch , PRO 3A, PRO 4A,PRO
12 branches
LBC-Coron Branch, Wao Lanao Del Sur Branch, PRO7 Branches,
PRO6 Branches
11. Official Receipts issued by banks/ACAs to the member do not reflect months
and quarter paid.
SM Bayad Centers, Bayantel NCR Central Branches
Landbank of the Philippines Gumaca, Quezon Branch(4A), Bayawan
City Branch (PRO7)

12. Late posting and over/under paid contributions in the remittances

made thru ACAs.
SRI Dasmarinas Cavite, Bayad Center Cavite Branches
MBTC Edsa-Magallanes Branch
Bank of Commerce NCR North Branch
Postal Bank PRO 1
Claims/Benefits
13. Members from the formal sector often complain that they are not
given the same priority when it comes to availability of medicines in the
hospital compare to other members. Most of their medicines and
supplies are bought outside the facility.
14. Members often complained of the lengthy processing of their
reimbursement or refunds.
15. Increasing number of Return to Hospital Claims due to exhausted
allowable days for confinement
16. Member-patients with dual membership were able to use both his
category types allowing him to have a total of 90 allowable days for
benefit availment.
17. The Newborn Screening Test is not availed by members because of
insufficient supply of filter cards. Members were given option to have the
newborn screening test to other healthcare institutions but failed to
inform members that the receipt paid for the newborn screening should
be submitted together with their claims in order to be reimbursed by
PhilHealth.
18. Members are complaining that they have out of the pocket expenses
even if the case rate amount is not yet exhausted
19. Claims processing for Hospital Sponsored Members (ORE) are not
being given priority. The hospital billing clerks maximize the 60-days
filling period before submitting the claims to LHIO. WHICH
HOSPITAL? (Eastern Visayas Regional Medical Center)
20. Members complain that it took a long time for their pre-cataract
authorization to approve.
21. Lack of Hospitals and Rural Health Unit in NCR who can provide
PCB1 and Animal Bite Package
22. 4Ps members have misconception on the NSD package, most of them
thought that they can use their benefits even on their 5th pregnancy
23. The Circulars enumerated below are commonly not followed by
Hospitals.
Observed Practice/s
Circular/s
Requiring unnecessary supporting documents even No. 7, s-2007
if members already have updated MDRs with No. 1, s-2013

Observed Practice/s
nothing to amend.
Requiring
the
submission
of
certificate
of
contribution/RF1 despite submission of a properly
accomplished and signed CF1
Non-acceptance of PCF1 as a substitute for MDR.
Non-compliance with Senior Citizen discounts and
VAT exemption
Not allowing outright deduction of Newborn Care
Package,
Hemodialysis,
Chemotherapy,
and
Radiotherapy and subsequently requiring direct
filling of claims.
Not compliance with the NBB Policy

Prescribing of Non-PNDF medicines

Non-acceptance of PhilHealth ID as a sole
requirement for the members benefit availment

Circular/s
No. 8, s 2007
No.
50,
s2012
No.
22,
s2012
No.
56,
s2012
No.
11,
s2011
No. 11B, s2011
No.
11,
s2011
No.
22,
s2012
No.
26,
s2009
No.
50,
s2012

Hospital asking payment for claim forms

No.
12
2010
Imposing a ceiling amount/ limit on the benefits of No.
20,
members in availing the case rate packages 2011
including the sponsored program members
PhilHealth Benefits deducted are not reflected in the No.
22,
Statement of Account given to members upon 2007
discharge.
Requiring Member Data Record to 4Ps member- No.
24,
patient even if the 4Ps ID is on hand
2012

s.
ss-

s-

Health Care Provider Relations

Some standards set forth by the Corporation are not followed by health care
providers. The following are observed or experienced by CARES on this
regard.
24. Hospitals are still uncertain with the new IRR, they want us CARES to
fully explain to them the guidelines and show circulars before approving
the members benefit availment.
25.
Hospital requiring other documentary requirements to memberpatient even if PhilHealth ID is on hand.

26. A surgeon is asking indigent patients to deposit before any operation

is done.
27. IHCP Portal in some hospitals are not functioning and appears to have
invalid account. WHICH HOSPITALS Siruma Municipal Hospital
28. Clerks are not aware that Newborn Care Package can still be availed
to newborns born as 5th child.
29. Some doctors are not cooperative with the hospital claims processor;
they do not accomplish the CF3 properly and on time
30.
The hospital does not have its own pharmacy. Clients are forced to
buy medicines outside the hospital.
31.
Hospitals ask payment for the second Claim Form 1 once they
committed error on the first fill up.
32.
Hospitals do not reimbursed receipts from the out of the package
expenses of members even though the full case rate amount is not yet
exhausted.
33.
During the days were the CARES is not present in the Hospital
(Sundays), hospital are not accepting supporting documentary
requirements for availment and advise members to directly file their
claims.
34. Hospital clerks assigned in the PhilHealth Section do not give uniform
information to clients and most of the time this lead to client's confusion.
Those who attended the training or seminars do not disseminate the new
policies to their colleagues.
35. The hospital's PhilHealth staff lack of coordination with one another.
Their specific tasks aren't well defined. Theses predicaments resulted in
RTH/RTS claims and inefficient provision of quality services to our
members.
36. The list of accredited doctors is not placed in conspicuous location in
the hospital. Clients expressed their frustrations because they were not
informed regarding the accreditation status of their doctors upon
admission.
37. Doctors prescribe expensive medicines and ordering unnecessary
diagnostic and laboratory examinations to fully exhaust the case rate
package.
38. Issues on the upcoming implementation of All Case Rate policy raised
questions and complaints from the hospital administration regarding
their responsibility for the payment of all professional fees to the
doctors/consultants. The need for additional personnel who will handle
the professional fee payment from PhilHealth was stressed out.