Replblic of the Philippines

Deparhnent ofHealth
OTTICE OF TI{E SECRETARY

JUN 3 0 2016

ADMINISTRATIVE ORDER
No. 20 t6 - OO39

SUBJECT: General Guidelines on the Retention and Distribution of Philippine

66Pooled
Health Insurance corporatign (PHIC) Professional Fees as
Funds" in Government Hosnitals in Accordance with PHIC All
Case Rate Policy

I. RATIONALE/BACKGROUND

Section 34-A of the RA 10606 entitled "An Act Amending Republic ActNo.7875,
otherwise known as the "National Health Insurance Act of 1995" states that "All payntent,s for
pro.fessional services rendered by salaried public providers shall be retained by the health
"
f'acility in which services are rendered and be pooled and distributed among health personnel.
Charge,s paid to public facilities ,shall be retained by the individual facili|, ill which services
vtere rendered and Jbr which payment was made. Such revenue,s shall be used to primarily
dufroy operctting co,gts other tltan salaries, to maintain or upgrade equipment, plant orfacility,
and to mainlain or improve the quality oJ'service in the. puhlic sector. "

Fee-for-service has been replaced by Case-Based Payment scheme as the main Provider
Payment Mechanism of PhilHealth. Initially starting out with 23 of the most common medical
and surgical cases as indicated by PhilHealth Circular (PC) No. I l-A and I l-B s. 201l, this
wasexpandedtotheAllCaseRatePolicyasperPCNo.3l s.2013. Inaddition,PCNo.35s.
201 3 has also set the ratesof reimbursements including professional fees (PF) for medical and
surgical cases. In this scheme, the cheque for the PF is issued under the name of the Chief of
Hospital or Medical Director for pooling and distribution. .

Fufthermore, PC No. ll-A & ll-B s.20ll, strengthened by PC No.3 s.2014, states
that for No Balance Billing (NBB) cases of patients admitted in government hospitals, no
further charges shall be made above and beyond the case rate package.

Manner of distribution of the professional fees however. has been left largely to the
discretion of the Health Care Institution (HCI). This has resulted into a largely heterogeneous
sharing scheme ofthe PF reimbursed by PhilHealth throughout government hospitals. Thus, in
the face of all the recent changes in pcrlicy as well as the non-uniform sharing of PF among
HCIs, the following guidelines are issued to ensure that these provisions are harmonized and
effective ly implernented.

u. SCOPE/COVERAGE

This Order shall cover all Departrnent of'Health (DOH) and Government Hospitals
(Specialty, Special, Medical Centers, and Regional Hospitals) and other facilities such as
infirmaries and sanitaria in consonance with the AllCase Rate Policy of PhilHealth.

Building l, San lazaro Compourd, Rizal Avenue, Sta Crua l0O3 Manila e Trunk Line 651-7800 Direct Line 7ll-9501
Fax-.743-l{29;743-1786 r URL: bttpJ/w\ryw.doh.sov.ph; e<tail: [email protected]

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III. DEFINITION OF TERMS

l. Pooled Funds -
refers to funds representing all PHIC Professional Fees, for
services rendered to service PHIC patients including NBB patients that are pooled
and distributed among hospital staff.

2. Doctor - a duly licensed Doctor of Medicine and Doctor of Dental Medicine.

3. Health Worker-as defined in Republic Act 7305, all persons who are engaged in
health and health-related work, and all persons employed in all hospitals, sanitaria,
infirmaries, health centers, rural health units, barangay health stations, clinics and
other health-related establishments owned and operated by the Government or its
political subdivisions with original charters and shall include, medical, allied health
professional, administrative and support personnel employed regardless of their
employment status.

4. No Balance Billing (NBB) Patients - members and dependents of the following

categories of membership:
a. Indigent - a person who has no visible lneans of income, or whose income is
insufficient for fbmily subsistence, as identified by the Department of Social
Welfare and Development (DSWD) based on specific criteria set for this
purpose in accordance with the guiding principles set forth in Article I of the
National Health lnsurance Act of 2013.
b. Sponsored - a member whose contribution is being paid by another individual,
government agency (including Online Registration Enrolment) or private entity
according to the rules as may be prescribed by the Philippine Health Insurance
Corporation (PHIC). This also includes patients identified and entered under the
Point Of Clare Program.
c. Household Help or"Kasambahay" as defined in Republic Act 10361 refers to
any person engaged in domestic work within an employment relationship such
as, but not limited to, the following: general househelp, nursemaid or *yqg,"
cook, gardener, or laundry person, but shall exclude any person who performs
domestic work only occasionally or sporadically and not on an occupational
basis.
d. Senior Citizen and Lifetime Members elieible for NBB availment.

5. Health Care Institution (HCI) - refbrs to health fbcilities that are PhilHealth-
accredited which includes, among others, hospitals, ambulatory surgical clinics,
TB-DOTS, freestanding dialysis clinics, primary care benefits facilities, and
maternity care package providers.

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IV. GENERAL GUIDELINES

l. The entire case rate amount, including the PF" shall be paid directly to the HCI
concerned.

2. The HCI shall withholcl the expanded withholding t* u, per BIR policy on
payments to be made to doctors or medical practitioners for their professional fees.
In addition, HCI shall withhold the final value added tax (VAT) on Covernment
Money Payment (GMP). if applicablc.

3. All Doctors and non-physician health workers are entitled to a share of the pooled
funds regardless of employnent status.

4. Policies and procedures on the manner and frequency of distribution of the pooled
funds shall be formulateri and enforced bv the HCI.

5. The NBB Policy shall apply to all indigents and sponsored members, kasambahays,
Lifetime Members, and Senior Citizens eligible for NBB availment. No additional
fees shall be charged beyond the case rate pa,:kage.

V. SPECIFIC GUIDELINES

A. Hospital workers who are entitledlnot entitled to u ,t u." from the "Pooled
Funds"

l. Pooling of all PF reimbursernents from PhilHealth shall be done to all cases

admitted in the designated PhilHealth bedslwards of DOH Hospitals.

2. All Doctors and non-physician health workers who are full-time, part-time,
pennanent, temporary. casual. contractual or from the medical pool are entitled
to a share frorn the "pooled funds" including those:
a. attending seminars/workshops, conficrences and/or lectures as covered by
corresponding Department Orders an,Jl or Hospital Orders;
b. on approved vacation, sick and other allowable leaves applicable under
existing Civil Service Laws;
c. on study leave or grant provi.'led such entitlement shall be limited to a
maxirnum of six (6) monlhs anel;
d. those who are detailed, in-service or lateral entry training in the hospital
where they are serving.
a

3. The fbllowing personnel shall not be entitled to a share from the pooled funds:
a. those who are meted with disciplinary ,ns45ures such as suspension or fine;
b. those who are on leave without pa);
c. those who are dctailed in other offices or institutions.

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 B. Share of full-time and part-time doctors and non-physician health workers to
the o'Pooled Funds"

While giving due recognition for the full service for quality patient care
provided by doctors and non-physician health workers who are not occupying full-
time positions, the Civil Servlce Laws on providing benefits of part-time staff must
be observed. Hence, part-time staffshall get half of the share of full-time staff.

C. Distribution of the Pooled Funds

l. The distribution of the pooled funds that shall be observed in all DOH and
Covernment Hospitals is as follows:
a. 50Yo for Doctors
b. 50%o for non-physician health workers
c. For the purposes of equity, the formula for the distribution of the pooled
fund among full-tirne and part-time doctors and non-physician health
workers shall be as followed:

POOLED F{.JND: a (c) -r b (c) *(%);whergin

"a": full-time doctors and other non-physician health workers
cc[" : p?rt-time doctors and other non-physician health workers who

shall receive 507i, of (c)

'6c'! - I 00a/" of cash that "a" or the number of full-time doctors who
will receive the full amount

2. HCIs shall be given the authority to determine the manner and frequency by
which PhilHealth shares for Doctors and non-physician health workers are to be
distrihuted.

3. Atl DOH and Government F{ospitals shall pass documentation of their

guidelines on the distribution of the pooled funds to the Office for Health
Operations (OHO; and DCFtr Regional Offices respectively for monitoring
purposes. Compliance to this Administrative Order shall be part of the
accreditation and lic*nsing requirements of Covernment Hospitals in their
respective DOH Regional Licensing Offices.

VI. ROLES AND RESPONSIBILITIES

l. Health Care lnstitutions - the HCI shall act as the withholding agent for the PF
reimbursements by PhilHealth, and shall determine the manner and frequency by
which the pooled funds for the PF of the hospital staff are to be distributed.

UN
 2. Medical Center Chiefs / Chief of Hospitals - Medical Center Chiefs shall ensure
equitable distribution of PF reimbursements from PhilHealth among the hospital
staff.

3. Office for Health Operations (OHO) - the OHO shall ensure that the new
guidelines are properly disseminated to all DOH and Government Hospitals. The
OHO shall also be responsible in monitoring compliance of DOH Hospitals to the
above-mentioned guideline in the distribution of PF.

4. DOH Regional Offices -DOH Regional Offices shall ensure compliance of

Government Hospitals in their area to this policy in the distribution of PF.

VII. REPEALING CLAUSE

Administrative Order No. 187 s. 2004 and all other issuances inconsistent with the
provisions of this Order are hereby repealed.

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VN [-6
fr EFFECTIVITY

This Order shalltake effect immediately.

JANETTE . LORETO-GARIN, MD, MBA.H

Secretary/of Health