Issues and Concerns Reported by P-CARES

3rd Quarter, 2014

Below is a summary of issues and concerns observed by the CARES deployed in
accredited healthcare institutions during the third quarter of 2014. The list is based
on submitted monthly reports collated by the PMT-CARES. For reference, it is also
indicated if the same issue or concern was reported in the previous 4 calendar
quarters. A mark means that it was reported while an means that it was not.
Issues and Concern
Membership
1. PhilHealth Circular 28 s-2013, i.e. a properly accomplished
PMRF will suffice as documentary requirement for
registration and declaration of dependents, had a positive
impact on membership. However, it has been observed
that grandparents, nieces, in-laws, siblings, etc. who could
not be declared as dependents are added by some
members, specifically indigent and sponsored members.
Information to correct member records is provided by PCARES in these instances.
2. MDRs and PhilHealth IDs of members, particularly
Sponsored and Indigents, contain multiple errors and
discrepancies causing problems during benefit availment.
Also, there are members who have more than one PINs
that are qualified for benefit availment. Some dependents
declared in the MDR are active members. Cases like these
are referred to the PRO/LHIO by the P-CARES.
3. Retirees are not aware of the need to change member
categories and assume that they will be automatically
enrolled as Lifetime Members.
4. Most of the sponsored and indigent members are not
aware that their membership has been renewed. On the
other hand, renewal of these members were not reflected
in the i-CARES system.
5. Some members have difficulty securing their MDRs due to
their geographic location.
6. There are members who are already employed for several
months/years but still do not have PIN.
7. There were some PhilHealth members reporting that some
of their declared dependents were omitted in their MDR,
those dependents are those with history of benefit

2013
3Q 4Q

2014
1Q 2Q

Issues and Concern

2013
3Q 4Q

2014
1Q 2Q

availment.
8. Some members complain that they have been repeatedly
updating their records but the system remains un-updated.
9. Members experience difficulty in producing proof of
relationship to their dependents. Some hospitals insist on
requiring such despite the new guidelines for declaring
dependents and benefit availment.
10. There are cases that some patients uses the PhilHealth
IDs and MDRs of other members.
11. Unstable IT system was observed as problem in the Pointof-Care Enrollment Program. Some hospitals encounter
technical problems which causes delay in the enrollment of
clients. There are also data inconsistencies between the
ORE system, i-CARES and MCIS. Membership categories
on the I-CARES were still not updated, indigent and
sponsored members were still not specified.
12. There are some hospitals who are willing to implement
the POC Program but have budgetary constraints.
13. There are reports that some POC hospitals do not properly
follow the thorough screening set by the DSWD for the
enrollment of hospital sponsored members. Medical Social
Workers easily approve POC membership even though the
patient is not considered as an indigent/critical poor.
14. With the implementation of 3/6 months of contributions
for benefit availment, an increase on membership was
observed especially pregnant women.
15. Members were unaware that there are PhilHealth Express
in malls that could help them with their membership
concerns.

Contributions
16. Employees, both from the public and private sectors,
complain about unposted contributions. Those who have
been deducted with contributions for many years are
disappointed that their employers did not properly remit
PhilHealth contributions and fail to submit reports on time.
17. The general sentiment towards the premium adjustment
is negative.
18. Members incurred underpayment/overpayment due to lack
of awareness on the new premium rates. Some accredited
collecting agents are also not informed/aware about the
said adjustment.

Issues and Concern

2013
3Q 4Q

19. Members are disappointed because of the late posting of

their contributions paid thru the ACAs. Also, official

receipts issued by banks/ACAs to the members do not
reflect months and quarter paid or have discrepancies in
data entries, e.g. wrong PIN and misspelled names. Lastly,
overlapping of contributions were also observed.
20. Some ACAs received retroactive payments from the
member even though the member is not any more allowed
to pay for the missed quarter
21. Some members of the formal economy were not
properly informed that they should pay their contribution
when they are on leave without pay.
22. Some employers sign the CF1 of their employees even if
they have been hired for less than 3 months.
23. Some member experience difficulty in paying their
contribution due to geographical location since there are
no available nearby LHIOs or accessible collecting agents
in their municipalities.
24. Members were confused of the need to have at least 3/6
months of contribution before confinement. They thought
that as long as they pay their contribution for a quarter or
at least 3 months they can automatically avail of the
benefits
25. Members who were separated from their work were
unaware that they need to continue their PhilHealth
contributions as self-earning individuals to avoid
gaps/lapses on their premium contributions and avoid
problems during benefit availment.
26. Members suggest that PhilHealth Express in malls
should accept and process premium contributions.
27. Some LHIO frontliners allow members to pay for the
current quarter without asking if the member/patient who
will avail of the benefit is currently admitted. This causes
problems during availment since members expect that
they could avail of the benefits.

2014
1Q 2Q

Claims/Benefits
28. Compared before, the P-CARES feel that PhilHealth
members are more aware of their benefits now. They
appreciate the simplified reimbursement process under
the All Case Rates policy. Also, they appreciate the
equitable benefits.

Issues and Concern

29. Members and hospitals appreciate the use of PBEF. It
makes benefit availment easier for them.
30. Fast turn-around time were observed during the
implementation of ACR, both hospitals and members were
satisfied. There is also decrease in RTHs claims.
31. Some of the members complain that they do not received
their Benefit Payment Notice.
32. Members were disappointed that they cannot fully utilized
their PhilHealth benefits due to the fact that most of their
supplies or diagnostic procedures needed were not
available in the hospital causing out of the pocket
expenses. Also, these out of the pocket expenses were not
refunded by the hospital even though the case rate amount
were not totally exhausted.
33. Members complain about the lengthy benefit
reimbursement process from government and LGU
hospitals.
34. Members demand that diagnostic and laboratory exams
that were done in the outpatient department of the
hospital should also be included to the benefits of
PhilHealth.
35. Employers were not familiar with the use of the new Claim
Form 1.
36. Some members expressed dissatisfactions with regards to
the benefits they have received from PhilHealth especially
those members confine in the private hospitals. Members
request for an increase amount of benefits.
37. There are suggestions to implement a price range for
medications, laboratories and other services provided by
accredited hospitals to avoid overpricing.
38. A lot of members (pregnant mothers) are not able to
avail of the Maternal Care Package since they are not
informed that the last 2 out of the 4 pre-natal checkups
should be done in the same facility where they will deliver.
39. There are members who complaint about the lack of
information dissemination effort about the PhilHealth
benefits. There are no brochures, flyers or other material
about it. According to them, they have never heard of the
benefits and the new policies until the P-CARES explained
it.
40. Some members thought that PhilHealth benefits depends
on their membership category. They thought that
Employed members have higher benefits compared to

2013
3Q 4Q

2014
1Q 2Q

2013
3Q 4Q

Issues and Concern

other categories.
41. A lot of common medical cases are not included in the ACR
Policy. Members are requesting for the increase in benefits
for some heart related medical and surgical procedures,
oncologic cases and the resuscitation package. There
remains a perception that benefits are less under the ACR
compared with the FFS.
42. A lot of hospitals in the regions still have no HCI portal
installed. There are also reports that the Portal is mostly
down or inaccessible due to poor internet connection,
electrical interruptions, technical problems, and other
unexpected circumstances beyond human control. It is also
not available 24/7 in some hospitals and on weekends.
43. There are problems observed in the HCI portal. First, the
restrictive data entry requirement results to errors in
encoding which constrains members from availing their
benefits. Second, there are instances where the system
does not yield any YES or NO response. Third,
payments remitted thru some ACAs are not reflected in the
PBEF. Fourth, the Portal does not detect whether
dependents are already declared by other members or has
their own PINs.
44. The Circulars enumerated below are commonly not
followed by Hospitals.
Observed Practice/s
Supporting documents are required even if
PMRF will suffice
Certificates of contribution/RF1s are
required despite submission of a properly
accomplished and signed CF1
Non-compliance with Senior Citizen
discounts and VAT exemption
Non-compliance with the NBB Policy
Hospital require 6 months of contributions
before admission to avail of the PhilHealth
benefits.

2014
1Q 2Q

Circular/s
No. 28, s2013
No. 8, s
2007
No. 50, s2012
No. 56, s2012
No. 11, s2011
No. 22, s2012
OM no.
0257, s.2013

Issues and Concern

2013
3Q 4Q

2014
1Q 2Q

Health Care Provider Relations

45. Some hospitals ask members to sign a blank Claim
Form 2 and some even force members to sign blank
statement of account
46. Hospital staff are still not updated and not fully
knowledgeable with some of the new PhilHealth circulars
thus causes problem/confusion on availment.
47. Most hospital still separates the breakdown of benefits
into room accommodation, drug and medicines etc.
48. Hospitals are not allowing outright deduction of
Newborn Care Package due to incomplete services.
49.Some hospitals performs surgeries beyond their capability and
alters the PhilHealth claim to cases compensable in their
hospital level

50. Some hospitals do not provide Statements of Account to

discharged patients.
51. HAMA is not compensable to PhilHealth according to
some hospital staff.
52. Accredited professional fails to inform the member if their
professional fee collected to them is already a net or gross
of PhilHealth. Members complain that hospitals do not
provide the breakdown of professional fees in the
statement of account.
53. Non-accredited doctors attend to PhilHealth members
which disqualify them from availing of benefits.
54. Some PhilHealth patients were discharged without final
diagnosis on their chart which causes problem during
processing of claims.
55. Hospital charges are higher for PhilHealth Members
compared to non-members which often results to excess
billing.
56. Some hospitals insist on having members update their
Member Data Record in LHIO. Attachment of PMRFs and
supporting documents are not allowed. Also, they do not
accept the PhilHealth ID as proof of membership,
attachment of MDR is required.
57. Some hospital do not provide statement of account to
discharge patients.
58. RTH concerns were all directed to CARES for
resolution.
59. The hospital demands CARES to sign on the claim forms
of patients.

Issues and Concern

2013
3Q 4Q

2014
1Q 2Q

60. The hospital requires CARES to do work beyond their

job description like encoding a patients claim or deducting
the PhilHealth benefits of some patients.
61. Hospital performs surgeries beyond their capability and
alters the PhilHealth claim to cases compensable in their
hospital level.

Issues and Concern

Point Of Care Enrolment
62. The system is unstable in some hospitals. Some encounter
technical problems which cause delay in the enrollment of
clients. There are also data inconsistencies between the ORE
system and iCARES.
63. The Medical Social Worker Service should be available 24/7
to enroll patients who are admitted at night.
64. Patients who are enrolled under POC are not provided with
payment slip details and certification by the Medical Social
Worker Service which causes delays in confinement to other
hospitals.
65. Some hospitals are willing to implement the Program but
have budget constraints.
66. Hospital experienced problem on enrolling patients in POC
since it took about 3 days before the patient will have their final
diagnosis and that is the only time that the SWA could
determine if the case of the patient was compensable or not
thats why enrolment to POC was delayed.
67. Previous HSM patient were not able to avail of the benefits
when admitted to other hospital because the POC hospital were

4Q
13

1Q 2Q
1 14
4

late on their payment for the said HSM.

68. Some patients who are enrolled as Hospital Sponsored
Members have their out of the pocket expenses during
confinement.
69. Some class C3 and D patients/members are enrolled only on
the date of discharge, hence defeating the NBB policy.
70. Point of Care remains suspended in some accredited hospitals
due to budget constraints and issues with the Commission on
Audit.
71. Point of Care (POC) enrollees are interviewed 2-3 days after
their admission after incurring thus out-of-pocket expenses.
72. There are reports that some POC hospitals do not reimburse
the out of the pocket expenses of their HSM.
73. There are instances when the POC program is used for political
purposes. There are Barangay Officials who refer patients to
the hospitals.
74. There are reports that some POC hospitals do not properly
follow the thorough screening set by the DSWD for the
enrollment of hospital sponsored members. There are patients
that were interviewed by the CARES that have the capacity to
pay premium contributions.

75.POC patients are paid for by the Municipal Mayor and not by the
hospital itself. Such cases require excessive documents such as
Barangay Clearance and Medical Certificate among others thus
resulting in late enrolment during which the patients have already
incurred out-of-pocket expenses
76.Some patients are being enrolled even though not classified under C3
or D.
77.MSWs easily approve POC membership even though the patient is not
considered as an indigent/critical poor.

Issues and Concern

All Case Rates
78. Hospital clerks have difficulty identifying which benefit should
the patient avail especially those with multiple diagnoses. They
also experience difficulty in determining the ICD 10 Codes for
some diagnoses since most of them do not have a background in
medical or health sciences.
79. Many common medical cases are not included in the ACR or
cannot be availed if admitted in levels 1 to 3 hospitals. A lot of
members turn irate when they discover that their confinement is
not compensable. They accuse PhilHealth of decreasing coverage
after increasing premium rates.

1Q
14

2Q
14

80. Patients and health care professionals request clarification

about the non-compensability of conditions/final diagnosis that are
not included in the ACR; particularly cases that have
manifestations and clinical symptoms which suggest rigid medical
attention and confinement.
81. Inconsistencies between some code in DOH ICD10 (coding of
hospital records) and codes on PhilHealth annexes. Some sort of
example, AGE in DOH ICD10 is A09 while in PhilHealth annexes
A09.0. Another one for DM Type 2, DOH ICD10 is E11.9 while in
PhilHealth annexes it is E10.9
82. Out-of-pocket expenses are paid by members in both
government and private hospitals even if the amount of case rate
has not been exhausted.
83. Members
with
continuous
treatments
such
as
cancer/hematology are appealing for the increase of case rates
and exclusion of their cases from SPC.
84. Hospital clerks were not familiar and experience difficulty on
processing claims of referral package.
85. There is a perception by some members that benefits are less
under the ACR compared with the FFS.
86. Hospitals have difficulty adjusting with the ACR policy but are
willing to learn. They are requesting PhilHealth to offer trainings,
and seminars.
87. Hospital complain about the new benefit payment notice. The
diagnosis or the case is not specified. Only the amount reimbursed
by PhilHealth is written.
88. A lot of accredited professionals are not aware of the new All
Case Rate Policy.
89. There are patients diagnosed with certain diseases but have
negative laboratory results. Prior to the ACR implementation, such
cases can still be covered provided certain factors which
corroborate the physicians diagnoses are assessed. The previous
requirement for these cases is the submission of CF3. Now that
there is no need to attach the laboratory results or CF3, hospitals
are hesitant to allow patients to avail of the PhilHealth benefits.
90. Members are not satisfied with the Resuscitation Package
which amounts to P4, 000 only for patients who died less than 24
hours after admission.
91. Some members suggest that diseases/cases covered by PhilHealth
be posted in the corporate website with the corresponding amount
of benefits.
92. Members suggested that Physical and Rehabilitation Therapy
should be included in the ACR.
93. Members requesting for the increase in benefits for heart related
medical and surgical procedures and oncologic cases.

94. Peritoneal Dialysis patients complain about the slow processing of

benefit reimbursement.
95. Members were not satisfied with the all case rate because
according to them they are still buying medicines and supplies
outside the hospital or some laboratories were unavailable.
96. Hospital clerks do not depend on the most resources used in
identifying 1st and 2nd case rate.
97. Sometimes there are differences in ICD 10 codes in annexes and
ICD 10 Books.
98. Fast turn-around time were observed during the implementation
of ACR, both hospitals and members were satisfied. There is also
decrease in RTHs claims.
99. Due to all case rate, since hospital received all the payment of
PhilHealth from their claims members question why their out
pocket expenses were not being refunded to them.
100. Stage 1 Essential Hypertension (I10.0), Dengue Stage 1
(A91.0), Dengue Stage 3 (A91.2) which are previously
compensable were cannot be found on the annexes of the new
circular for all case rate.
101.

Benefits for orthopaedic cases are reportedly insufficient.

HCI Portal and PBEF

102. The use of PBEF makes benefit availment easier for members. A
lot of them are appreciative of its implementation.
103. Hospitals are requesting for an orientation on the HCI portal
and PBEF.
104. Some hospitals require the P-CARES to operate the HCI portal.
105. Some hospitals use the PBEF only for viewing the patients
eligibility but not as a replacement for the MDR.
106. Payments remitted thru some ACAs are not reflected in the
PBEF. Hence, members are tagged as not eligible and official
receipts are required for attachment.
107. Hospital requests for clarification about the allowed signatories
in the PBEF in case the member cannot sign.
108. There were members who want to settle their PhilHealth claims
prior to discharge. However, they were not allowed to do so as the
system requires the date of discharge for accessing the members
eligibility.
109. The portal sometimes shows inaccuracy like two siblings dependent
are already in the MDR, however since both of them are admitted the
first is ok in the portal and confirms YES but the other patient confirms
NO.

110. Case wherein a member requested confinement journal in LHIO

which stated that 45 days was not yet exhausted but in PBEF it
yields a NO response and a remark of 45 days has been exhausted

and sometimes vice versa.

111. Encountered OFW members with valid validity period on
ICARES but yields a NO response on PBEF.
112. Hospitals are asking for a policy that will apply to patients who
have had PBEFs generated but extended confinement for valid
concerns. Can the hospital be allowed to edit the PBEF in this
case?
113. Some generated PBEF have no reference number and did not
appear on PBEF history.
114. Inconsistent response from PBEF, on initial checking it will say
YES and the patient could avail of the benefit but afterwards it will
say NO upon printing the PBEF form or vice versa.
115. Case wherein a member requested confinement journal in LHIO
which stated that 45 days was not yet exhausted but in PBEF it
yields a NO response and a remark of 45 days has been exhausted
and sometimes vice versa.
116. Restrictive data entry requirement result to errors in encoding.
Hence, the PBEF yields a NO response. Although this is a good
security feature, some members might be denied from availing
their benefits due to encoding issues.
117. Encountered OFW members with valid validity period on
ICARES but yields a NO response on PBEF.
118. Poor internet connection, electrical interruptions, technical
problems, and other unexpected circumstances beyond human
control cause delays in generating the PBEF during discharge.
What can the hospital do in events like these? Will the PBEF
remain valid after the patients discharge, particularly in instances
where the HCI portal could not be accessed on the day of
discharge?
119. Hospital requires a lot of documentary requirements (marriage
contract, Birth certificate, etc.) when the PBEF yields a NO
response. The PMRF should have been sufficient to update the
members data.
120. There are hospitals where only one staff knows how to operate
the HCI portal. In his/her absence the MDR and CF1 are required
for submission.
121. There are instances where the PBEF yields a YES upon
admission then yields a NO at the time of discharge.
122. There are hospitals that still requires the submission of MDR
and other documents even if the PBEF yields a YES.
123. Some hospital dont allow the use of PBEF on dialysis sessions
and require the old set of requirement.
124. There are reported cases where the dependent is declared in
the iCARES and MDR but the PBEF yields a NO with an
undeclared dependent remark.

125. PBEF answers YES even though the dependent declared in ICARES was invalid.
126. There are instances where the system does not yield a YES or
NO response.
127. Still a lot of hospitals in the regions have no HCI portal
installed.
128. The HCI portal is mostly down or inaccessible. It is also not
available 24/7 in some hospitals and on weekends.
129. There are OFW members with a posted contributions in the iCARES and MDR but yields a NO response in the PBEF with a
proof of contribution required remark.
130. PBEF does not detect if dependents are declared by other
members or has their own PIN.
131. Some hospital only print PBEF if it yields a YES response on
eligibility and if yields a NO response they just require the
member the basic requirements on benefit availment.
132. Hospital was not using PBEF consistently.

Issues and Concern

NHTS-PR/4Ps
It is hard to differentiate between NHTS-PR and LGU Sponsored
Members using the iCARES.
134. Validity dates of indigent and sponsored members are not reflected in
the iCARES system. NHTS-PR/LGU sponsored members whose
membership with un-updated membership validity are required to go to
the LHIO to secure a CE1 Form.
135. MDR of Indigent members has still a lot of discrepancies. Most of
them cannot provide supporting documents to correct those
discrepancies which leads to non-availment.
136. A lot of 4Ps individuals are not registered with PhilHealth.
137. A lot of 4Ps and indigent members have dual PINs or other
membership categories.
133.

138. CARES observed that there were still 4Ps IDs which were not valid as per
the circular 24s. 2012.
139. NBB entitled 4Ps incur out-of-pocket expenses due to unavailability of

drugs, medicines and laboratory procedures in hospitals.

4Ps members insists that their grandchildren should be entitled to
avail of the PhilHealth benefits.
141. Are Ahon Pamilyang Pilipino IDs recognized as 4Ps IDs. Are bearers of
said IDs eligible to avail of the benefits?
142. Some 4Ps members who have their Orange Card prefers to use it than
their PhilHealth membership.
140.

Some 4Ps members only have certifications which is not valid for
benefit availment.
144. All 4Ps members are verified first to DSWD before availing of benefits
which causes delay since we have no direct access or contact person on
DSWD.
145. Still a lot indigent members have no or sometimes invalid validity
period posted in the i-CARES system.
146. Some patients use fake 4Ps ID and Kasunduan (Certificate). Some
have no records with the DSWD.
147. Distribution and screening of indigent/sponsored members being
questioned by Hospitals. Families in great need of help and have no
means to pay are removed from the program while some who a family
member working abroad or evidently has the capacity to pay are given
coverage.
148. There were indigent members who already deceased for a long time
but still have active membership.
149. There were still a lot of discrepancies on the data of the member and
their dependents on the PhilHealth database.
150. 4Ps members insist on using the 4Ps IDs over the yellow MDR or
PhilHealth Cards on the assumption that they will not be required to pay
anything if they use the former
143.

151. There are 4PS member whos using other peoples identity. They call it as
"GAMPAN" which means they take over the identity of the person in ID to use
its benefits.

152. Some members of the NHTS are actively working abroad and
currently employed.
153. MDR were not given to the NHTS-PR members but being hold on the
Rural Health Unit.
154. 4Ps member who use the family name of her live-in partner claiming
that they are married affects their eligibility. DSWD advised them to use
the last name of the live-in partner which is not supposed to be used
considering that there are no legal papers to support such object.
155. Indigent members have no idea about the No Balance Billing Policy.

Consolidated by:
_________________
Richard P. Sonsing
PMT-CARES