(NAR) VOL. 25 NO. 1 / JANUARY - MARCH 2014
Adopted: 09 January 2014
Date Filed: 17 February 2014
I. RATIONALE
In 2011, PhilHealth has implemented case based payment scheme which offers a more predictable and equitable benefit payment based on patients’ medical condition. Along with the introduction of case payment is the introduction of the No Balance Billing (NBB) Policy, which provides that no other fees or expenses shall be charged or be paid for by the indigent patients above and beyond the packaged rates.
However, resource constraints have proved to challenge the effective implementation of the NBB policy. It necessitates, among others, the strong political will of both national and local government to do their share in resource management and policy enforcement to assure that every poor Filipino is truly protected against financial risk.
Section 43 of the Implementing Rules and Regulation of Republic Act No. 10606 (National Health Insurance Act of 2013) states that, “No other fee or expense shall be charged to the indigent patient, subject to the guidelines issued by the Corporation. All necessary services and complete quality care to attain the best possible health outcomes shall be provided to them.” This Circular is crafted for the strengthening and improving the enforcement of the NBB policy.
II. COVERAGE AND SCOPE
A. NBB Patients
B. Benefits Covered
a) All Case Rates
b) 23 Case Rates as enumerated in PhilHealth Circular No. 11, s-2011
c) Case Type Z benefits
d) Leptospirosis Package
e) TB-DOTS Package
f) Outpatient Malaria Package
g) Animal Bite Treatment Package
h) Voluntary Surgical Contraception Package
a) Outpatient HIV/AIDS Treatment (OHAT) Package
b) Severe Acute Respiratory Syndrome (SARS) Package
c) Avian Influenza Package
d) Intrauterine device (IUD) insertionC. Health Care Institution Covered
a) Contracted facilities for Z Benefit Packages b) Ambulatory Surgical Clinics c) Freestanding Dialysis Centers d) TB DOTS Centers e) Birthing Homes f) Infirmaries and dispensaries - For private infirmaries and dispensaries, NBB policy shall only apply to claims application for Maternity Care Packages and Newborn Care Packages. All other benefits are not subject to the NBB policy in private infirmaries.
Type of Facility Gov't Private Benefits Covered by NBB 1. Hospitals - x All applicable benefits covered by NBB in hospitals 2. Outpatient Malaria Providers - x Outpatient Malaria Package 3. Animal Bite Treatment Centers - x Animal Bite Treatment Package 4. Treatment Hubs - x OHAT Package 5. Contracted Hospitals for Z Benefit Package - - Case Type Z Benefits 6. Ambulatory Surgical Clinics - - All benefits covered by NBB including cataract extraction, BTL, vasectomy 7. Freestanding Dialysis Clinics - - Dialysis Package 8. TB DOTS Centers - - DOTS Package 9. Birthing Homes - - MCP, NCP IUD insertion 10. Infirmaries/ Dispensaries - -* Government infirmaries: All benefits covered by NBB including vasectomy
*Private infirmaries: MCP and NCP onlyIII. GENERAL POLICIES
IV. ENABLING MECHANISMS
A. MEMBERSHIP AND ELIGIBILITY OF MEMBERS
To ensure that qualified NBB members and dependents will not have any out-of-pocket expenditures, it is imperative that membership verification should be done prior to hospital admission and availment of outpatient services. All government facilities should have the capacity for real time verification of membership and eligibility.
B. BENEFITS OF THE NBB PATIENT
a. |
Ensuring availability of drugs and supplies.
Facilities shall establish a mechanism whereby all necessary
medications, diagnostic tests, and supplies are made available in the
facility. |
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i. |
Hospital Formulary. In compliance to DOH AO No. 51 of 1998,
the hospital Therapeutics Committee shall maintain a list of drugs the
agency will keep on stock, use, buy or prescribe based on the latest
edition of the Philippine National Formulary (PNF). |
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ii. |
The Therapeutics Committee shall
perform appropriate forecasting to ensure that the hospital has an ample
supply of drugs to meet the prevailing morbidity and mortality profile
in their respective facilities in accordance with clinical practice
guidelines (CPGs). |
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iii. |
All prescribed medications
to qualified NBB members and dependents shall be made available and be
dispensed exclusively from the hospital pharmacy. |
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b. |
Unavailability of drugs. In
any instance where medications and its alternatives are not available,
the facility shall undertake to make sure that medications are available
at no cost to the patient through the following mechanism: |
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i. |
Consignment. PhilHealth supports
other legal modes of procurement such as consignment. Government
hospitals may consign, contract or enter into agreement with licensed
suppliers of drugs, supplies and diagnostic services to ensure
availability of resources. However, hospitals are highly discouraged to
consign, contract or enter into agreement with third parties owned by
hospital employees and their immediate relatives to avoid potential
conflict of interests. |
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ii. |
Prescribing of medications. It
is incumbent upon the health care professionals to ensure that their
prescribed medications and supplies are available within the hospitals’
pharmacy. The physician shall only prescribe PNF drugs in generics and
brand names should not to be indicated. In instance where the preferred
prescriptions are not available within the pharmacy, the provider must
first consider other therapeutic alternatives which may be given in lieu
of the unavailable prescribed medication. |
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iii. |
Use of generic substitutions.
Health care institutions shall strictly observe and impose the use of
generic substitutions to provide for the needs of patients within the
resources available. |
a. Availability of laboratory tests and diagnostic procedures. Health care institutions shall perform all necessary laboratory and diagnostic procedures to establish definitive, accurate diagnosis and further achieve the best possible outcome. b. Unavailability of resources. i. In instances where a particular test is not available for any reason and the hospital cannot carry out required laboratory or diagnostic tests, the hospital shall make necessary referral and endorsement to the nearest government hospitals or private diagnostics center at no cost to the patient. ii. For non-ambulatory patients, it is incumbent upon the hospital to make necessary arrangements for patient conduction via an ambulance without any additional cost to qualified NBB members and dependents.
Health care professionals must not charge over and above the professional fees provided by the Program for members admitted to a service bed.
a. Premised to the pooling of professional fee component for PhiIHealth reimbursements within the facility, salaried physicians shall not charge additional professional fees to qualified NBB members and dependents. b. Non-salaried physicians (consultants) shall not charge additional professional fee to qualified BB members and dependents admitted in ward type of accommodation.
a. Health care professionals shall not resort to unnecessary referrals for the mere reason of lack of resources including, but not limited to, laboratory, diagnostic procedures, and the likes. b. However in instances where a referral is deem necessary, providers shall make necessary arrangements such as endorsement, transportation and accommodation.
a. Hospitals are encouraged to develop NBB packages corresponding to the case-rate packages of PhilHealth in order to ensure that the resources necessary for each package are pre-determined, available and easily quantifiable in relation to demand. b. Such NBB packages shall include accommodation, use of operating room complex, professional fees, drugs and medicines including biologicals, supplies, as well as diagnostic and therapeutic procedures.C. INCENTIVES
D. EFFECTIVE INFORMATION DISSEMINATION
E. MONITORING AND EVALUATION
PhilHealth through the Standards and Monitoring Department shall regularly conduct monitoring on facilities’ compliance to the NBB policy of PhilHealth.
a) If a provider has been found to be in violation of the existing rules and regulations of the NBB policy, the HCDMD Chief through AQAS and Legal Services Unit shall conduct validation by performing domiciliary visit. b) The findings shall then be submitted to the RVP through the HCDMD for appropriate action.G. GRIEVANCE AND ACCESS TO COMPLAINTS DESK
Corporate Action Center a) Contact Number : 441-7442 b) Email Address : actioncenter@philhealth.gov.ph c) Facebook : www.facebook.com/PhilHealth d) Twitter : @teamphilhealthH. PENALTIES
For any violation of this Circular, the terms and conditions of the signed Performance Commitment and all existing related PhilHealth circulars, office orders and directives shall be dealt with and penalized in accordance with the pertinent provisions of RA 7875, as amended, and its Implementing Rules and Regulations.
VI. SEPARABILITY CLAUSE
In the event that a part or provision of this Circular is declared void by any Court of Law or competent authority, those provisions not affected by such declaration shall remain valid and effective.
VII. EFFECTIVITY
This Circular shall take effect 15 days after its publication in a newspaper of general circulation and a copy thereof shall be deposited thereafter with the Office of the National Administrative Register, University of the Philippines Law Center.
For the information and guidance of all concerned.
(SGD) ALEXANDER A. PADILLA
President and CEO