Issues and Concerns Reported by PCARES

2nd Quarter, 2014

Below is a summary of issues and concerns observed by the P-CARES
deployed in accredited healthcare institutions during the second quarter of
2014. The list is based on submitted monthly reports collated by the PMTCARES. For reference, it is also indicated if the same issue or concern was
reported in the previous 3 calendar quarters. A mark means that it was
reported while an means that it was not.
2013
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. Lifetime members 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 members are not aware that their
membership has been renewed by their LGUs. On the
other hand, renewal of some members per the LGUs
master list is not reflected in the i-CARES system.
5. Some members have difficulty securing their MDRs and
paying their contributions to the LHIOs due to geographic
location.

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Issues and Concern
6. Some members complain that they have been repeatedly
updating their records but the system remains un-updated.
These cases are mostly referred to the LHIOs.
7. 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.
8. 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 and i-CARES
9. There are some hospitals who are willing to implement the
POC Program but have budgetary constraints.
Contributions
10. 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.
11. The general sentiment towards the premium adjustment
is negative.
12. Members incurred underpayment due to lack of
awareness on the new premium rates. Some accredited
collecting agents are also not informed/aware about the
said adjustment.
13. Some employers remit contributions but fail to submit
reports on time.
14. 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.
15. Some members of the formal economy were not
properly informed that they should pay their contribution
when they are on leave without pay.
16. Some employers sign the CF1 of their employees even if
they have been hired for less than 3 months.
17. There are no accessible collecting agents in some
municipalities.

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2013
Issues and Concern
18. There are employers who require employees to present
a certificate of confinement from the hospital before
providing a signed CF1.
19. There is a suggestion that the P-CARES and other
frontline employees be provided with an interactive list of
Accredited Collecting Agents. The list uploaded in the
website is not user friendly.
Claims/Benefits
20. Compared before, the P-CARES feel that PhilHealth
members are more aware of their benefits. They
appreciate the simplified reimbursement process under
the All Case Rates policy. Also, members appreciate the
equitable benefits.
21. Members and hospitals appreciate the use of PBEF. It
makes benefit availment easier for them.
22. Members complain about the prohibition of direct filing.
They
encounter
difficulties
complying
with
the
requirements during confinement.
23. Members complain about the lengthy benefit
reimbursement process from government and LGU
hospitals.
24. Employers are not familiar with the use of the new
Claim Form 1.
25. Lifetime Members request for PCB1 benefits. They also
suggest PhilHealth coverage for general check-up in
Levels 1 to 3 Hospitals.
26. There are suggestions to implement a price range for
medications, laboratories and other services provided by
accredited hospitals to avoid overpricing.
27. Members and hospital staff are disappointed that the
approval of pre-cataract authorization takes more than 7
days. The lag time causes delays in surgery and
rescheduling. Also, most hospital staff are not informed
that Saturdays and Sundays are not included in the
counting of 7 days.
28. A lot of members 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.
29. Members complain about the lack of information

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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.
30. Hospitals have difficulty adjusting with the ACR policy
especially in determining the ICD 10 Codes of some
diagnoses. They are requesting PhilHealth to offer more
trainings, and seminars on these topics.
31. 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.
32. 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.
33. 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.
34. 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

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Circular/s
No. 28, s2013
No. 8, s
2007
No. 50, s2012
No. 56, s-

2013
Issues and Concern
Observed Practice/s
discounts and VAT exemption
Non-compliance with the NBB Policy
Hospital require 6 months of contributions
before admission to avail of the PhilHealth
benefits.

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Circular/s
2012
No. 11, s2011
No. 22, s2012
OM no.
0257, s.2013

Health Care Provider Relations

35. Some hospitals admit patients with inadmissible
diagnoses to avail of the PhilHealth benefits or sometimes
alter diagnoses.
36. Some hospitals ask members to sign a blank Claim
Form 2 and some even force members to sign blank
statement of account.
37. Hospitals are not allowing outright deduction of
Newborn Care Package due to incomplete services.
38. Some hospitals do not provide Statements of Account to
discharged patients.
39. Non-accredited doctors attend to PhilHealth members
which disqualify them from availing of benefits.
40. Some hospitals have inadequate medicines, supplies
and laboratory procedures which cause out-of-pocket
expenses to indigent members.
41. Members complain that hospitals do not provide the
breakdown of professional fees in the statement of
account.
42. Some pharmacies of government hospital are not open
24/7. Members had to purchase medicines outside the
hospitals if they are admitted after pharmacy hours, on
Sundays and holidays.
43. Some hospital staff depend on P-CARES determine the
ICD codes.
44. Hospitals are not consistent with the implementation of

2013
Issues and Concern
3 months over 6 months of contribution for benefit
availament. Some of them require 9 over 12 months of
contribution for surgical procedures.
45. Hospital charges are higher for PhilHealth Members
compared to non-members which often results to excess
billing.
46. Some hospital do not honor the PhilHealth CARES Form
1 as a replacement for the MDR
47. 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.

Consolidated by:
_________________
Richard P. Sonsing
PMT-CARES

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