Issues and Concerns Reported by P-CARES 3 Quarter, 2014: Issues and Concern 2013 2014 3Q4Q1Q 2Q Membership
Issues and Concerns Reported by P-CARES 3 Quarter, 2014: Issues and Concern 2013 2014 3Q4Q1Q 2Q Membership
2013
3Q 4Q
2014
1Q 2Q
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.
2013
3Q 4Q
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.
2013
3Q 4Q
2014
1Q 2Q
2013
3Q 4Q
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
2013
3Q 4Q
2014
1Q 2Q
2013
3Q 4Q
2014
1Q 2Q
4Q
13
1Q 2Q
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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.
1Q
14
2Q
14
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.
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.
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
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