Revised Minimum Guidelines for the Retention, Sourcing and Distribution of PHIC Professional Fees as "Common Funds" in DOH Hospitals ( DOH Administrative Order No. 2004-0187 )

November 30, 2004

DOH ADMINISTRATIVE ORDER NO. 2004-0187

 

I. RATIONALE/BACKGROUND

Section 35 of Republic Act No. 7875 (National Health Insurance Act of 1995) entitled "Fee-for-service Payments and Payments in General" specifically provides that "Fee-for-service payments may be made separately for professional fees and hospital charges, or both, based on arrangements with health care providers. This fee shall be based on a schedule to be established by the Board which shall be reviewed every three (3) years. Fees paid for professional fees rendered by salaried public providers shall be allowed to be retained by the health facility in which services are rendered and be pooled and distributed among health personnel. Charges paid to public facilities shall be allowed to be retained by the individual facility in which services were rendered and for which payment was made. Such revenues shall be used to defray operating costs other than salaries, to maintain and upgrade equipment, plant or facility, and to maintain or improve the quality of service in the public sector." aASDTE

In addition, Item M, Section 47, Rule VIII Payment of Claims of the Revised Implementing Rules and Regulations of Republic Act No. 7875 (National Health Insurance Act of 1995) dated March 18, 2004 states that "Professional fees for services rendered by salaried health care providers may be retained by the health care institution in which the services are rendered for pooling and distribution among health personnel. The manner of distributing the professional fees is left to the discretion of the health care institution."

By virtue of R.A. No. 7875 (National Health Insurance Act of 1995) and the General Appropriations Act's Special Provision on DOH Hospital Income Retention, the DOH Hospitals are allowed to retain PHIC payments covering hospital charges and professional fees in a Trust Fund. Historically the PHIC professional fees (PF) is known as "Common Funds" where PHIC PF for services rendered to PHIC patients shall be pooled and distributed among hospital staff.

In order that these provisions are properly and effectively implemented among all hospitals under the Department of Health (DOH), the following guidelines are reiterated and prescribed.

II. SCOPE/COVERAGE

This Order shall cover all Department of Health Hospitals (Medical Centers, Special Hospitals, Regional and District Hospitals, Research Hospitals and Sanitaria) and Centers for Health Development.

III. DEFINITION OF TERMS

A. PHIC Professional Fees (PPF) — refers to the amount allocated by PHIC to pay for the Professional Fee of the attending physician

B. Over and above Professional Fee (OPF) — refers to the difference between the PPF and the prevailing Professional Fee of the attending physician

C. Common Funds — refers to funds representing all PHIC PF for services rendered to PHIC patients that are pooled and distributed among hospital staff

D. Relative Unit Value (RUV) — is a number assigned to surgical procedures identified by PHIC that reflects its relative weight or its degree of complexity as compared to another. Therefore, the more difficult the procedure is, the higher is its relative unit value.

E. Relative Value Scale (RVS) — is a systematic listing and coding of surgical procedures where each procedure is assigned a corresponding RUV. Each procedure or service is identified with a five-digit code. With this coding and recording system, the reporting of procedures performed by physicians are simplified and accurately identified.

F. Peso Conversion Factor (PCF) — the amount that will be multiplied with the RUV of the procedures to get PHIC benefit for professional fee. The current PCF is P40. DCcTHa

IV. GENERAL GUIDELINES

A. Professional Fees for Patients enrolled under the National Health Insurance Program or PHIC patients

1. The Total Professional Fee paid by the PHIC patients to the attending physician, whether full time or part time medical staff of the hospital, consists of the PPF and OPF:

2. For patients who are PHIC members admitted to the pay rooms and PHIC wards, the professional fees should take into consideration the paying capacity of the patient, the prevailing rates in the area, the outcome of treatment and the ability of the Medical Specialists. Under the best conditions, the following rules shall apply:

a) The professional fees shall be guided by a standardized schedule of fees of all procedures, surgical interventions and examinations based on the RUV set by the current RVS of the PHIC. This fee schedule shall have its own PCF based on the current market rates in the area and also integrates PHIC's current PCF. As for the PHIC wards, the expected PCF should be substantially equal to the current PHIC's PCF.

b) For interventions which are not yet in the current RVS of PHIC (particularly management of non-surgical conditions), the Professional fees shall be guided by existing market rates in the area taking into consideration the occupied room rate and the specialty society recommended room rate. However, once these interventions are included in the RVS, the above rules in 2.a shall apply. ACETIa

c) A proper accounting system of the disbursement of the "common funds" shall be established by the hospital concerned.

B. Hospital workers who are entitled/not entitled to a share from the "Common Funds"

1) All hospital workers, who are full-time, part-time, permanent, temporary, casual, contractual or from the medical pool, whether Medical (Doctor), Dentist or Non-Medical (non-doctors) are entitled to a share from the "common funds" including.

a) those attending seminars/workshops, conferences and/or lectures as covered by corresponding Department Orders and/or Hospital Orders;

b) those on approved vacation, sick and other allowable leaves applicable under existing Civil Service Laws;

c) those on study leave or grant are entitled to a share of the "common funds" provided such entitlement shall be limited only to a maximum of six (6) months;

d) those on approved in-service training are entitled to a share of the "common funds" provided that the recipient has not received such benefit from the sending/mother agency;

e) those who are detailed in the hospital are entitled to a share of the "common funds" from the hospital where they are serving.

2) Personnel who are on suspension and on leave without pay shall not be entitled to the common funds.

C. Share of Full time and Part time Medical Staff to the "Common Funds"

While giving due recognition for the full service for quality patient care provided by medical staff who are not occupying full time positions, the Civil Service Laws on providing benefits of part-time medical staff must be observed. Hence, part time medical staff shall get half of the share of full time medical staff.

D. Sourcing, Pooling, and Distribution of PMC Professional Fees:

1.) As a move towards greater Hospital management flexibility and autonomy supporting the Hospital Reforms of the Health Sector Reform Agenda, and considering the situational variations of the different regions regarding PHIC coverage and hospital reimbursements, all DOH hospitals shall formulate institutional guidelines for the Sourcing and Pooling of PHIC Professional Fees as Common Funds. In the preparation of these Guidelines, a committee represented by major sections of the hospital shall be created to recommend to the Chief of Hospital the manner of Sourcing, Pooling and Distribution of PHIC Professional Fees. The General Guidelines stated in this A.O. must be considered. The Chief of Hospital shall approve the formulated institutional guidelines. TcSCEa

2.) The Hospital concerned shall submit to the Center for Health Development (CHD) in their respective areas the Guidelines for the Sourcing and Pooling of PHIC Professional Fees as Common Funds, for reference and monitoring purposes. In the case of Metro Manila, except for hospitals which are under CHD Metro Manila, all other Metro Manila Hospitals shall submit to the Office of the Undersecretary for Health Operations the said Guidelines.

3.) The CHD/Office of the Undersecretary for Health Operations shall create an oversight committee to review the institutional guidelines submitted by the hospitals and develop guidelines on the operational process of monitoring and implementation of the institutional guidelines in the DOH Hospitals.

4.) Any clarification/comments regarding the implementation of the institutional guidelines shall be referred to the oversight committee in their respective region.

V. REPEALING CLAUSE

Administrative Order No. 42 s. 2001 and all other issuances inconsistent with the provisions of this Order are hereby repealed.

VI. EFFECTIVITY

This Order shall take effect immediately.

(SGD.) MANUEL M. DAYRIT, MD, MScSecretary of Health