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. Inconsistencies on the validity periods of Sponsored program
members (PhilHealth ID versus iCARES data).
9. 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
10. 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.
11. In some ACAs, such as LBC, details on the PAR are not printed
clearly.
Claims/Benefits

12. Members from the formal sector often complains 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.
13. Members often complained of the lengthy processing of their
reimbursement or refunds.
14. Increasing number of Return to Hospital Claims due to
exhausted allowable days for confinement
15. Member-patient with dual membership were able to use both his
category types allowing him to have a total of 90 allowable days for
benefit availment.
16. There is a confusion between the old and new IRR regarding
Non Spontaneous Delivery of children below 21y/o. If the parents
membership will be used or the child need to apply and use her
own membership.
17. Dialysis patients have been expressing their desire to have the
45-day limit extended for them and their hemodialysis sessions.
18. 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.
19. Members are complaining that they have out of the pocket
expenses even if the case rate amount is not yet exhausted
20. 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.
21. Members complain that it took a long time for their pre-cataract
authorization to approve.
22. Lack of Hospitals and Rural Health Unit in NCR who can
provide PCB1 and Animal Bite Package
23. 4Ps members have misconception on the NSD package, most of
them thought that they can use their benefits even on their 5 th
pregnancy
24. Hospitals seem doubtful of rules imposed by the Corporation.
The Circulars enumerated below are commonly not followed.
Observed Practice/s
Requiring unnecessary supporting documents
even if members already have updated MDRs
with nothing to amend.
Requiring the submission of certificate of
contribution/RF1 despite submission of a

Circular/s
No. 7, s-2007
No. 1, s-2013
No. 8, s 2007
No.
50,
s-

Observed Practice/s
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

Circular/s
2012
No.
22,
s2012
No.
56,
s2012
No.
11,
s2011
No. 11B, s2011
No.
11,
s2011
No.
22,
s2012
Prescribing of Non-PNDF medicines
No.
26,
s2009
Non-acceptance of PhilHealth ID as a sole No.
50,
srequirement for the members benefit availment
2012
Hospital asking payment for claim forms

No.
12
2010
Imposing a ceiling amount/ limit on the benefits No.
20,
of members in availing the case rate packages 2011
including the sponsored program members
PhilHealth Benefits deducted are not reflected in No.
22,
the Statement of Account given to members 2007
upon 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.
25. Hospitals are still uncertain with the new IRR, they want us
CARES to fully explain to them the guidelines and show before
approving the members benefit availment.
26. Hospital requiring other documentary requirements to memberpatient even if PhilHealth ID is on hand.
27. A surgeon is asking indigent patients to deposit before any
operation is done.

28. IHCP Portal in some hospitals are not functioning and appears
to have invalid account.
29. Clerks are not aware that Newborn Care Package can still be
availed to newborns born as 5th child.
30. Some doctors encourage their patients to buy drugs and
medicines on pharmacies that they own.
31. Some doctors are not cooperative with the hospital claims
processor; they do not accomplish the CF3 properly and on time
32. The hospital does not have its own pharmacy. Clients are forced to
buy medicines outside the hospital.
33. Hospitals ask payment for the second Claim Form 1 once they
committed error on the first fill up.
34. 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.
35. Hospitals not allowing CARES to conduct ward visits for
information
education
campaign
(IEC)
about
PhilHealth
membership.
36. 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.
37. Some PhilHealth Clerks still require clients to have PCF1 even
though they already have MDR on hand.
38. Hospital clerks delegates her task to the PhilHealth CARES
assigned in the hospital that is beyond his/her job description
39. PhilHealth clerk is still asking for PCF1 to patients who are
already discharged.
40. Some hospital automatically advise unmarried patient who avail
of NCP to directly file their claims to avoid possible RTH due to
unavailability of supporting documents
41. Hospital clerks assigned in the PhilHealth Section don't 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.
42. The hospital's PhilHealth Section is closed during weekends and
holidays. Those admitted and discharged during long weekends
have no choice but to pay for their whole bill. They may file their
claim the following workday but they'll have to wait for
PhilHealth's claims payment to get their reimbursement.
43. 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.
44. 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.
45. Doctors
prescribe
expensive
medicines
and
ordering
unnecessary diagnostic and laboratory examinations to fully
exhaust the case rate package.
46. 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.
47. IHCP is always inaccessible due to hospitals poor internet
connection
48. Hospitals are confused on how to deduct the senior citizen
discount