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5TH Topic- Future Direction FOR Client Education -1

Bachelor of Science in Nursing (University of Perpetual Help System DALTA)

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Topic: Future Direction for Client Education

RESEARCH

l. Third-Party Reimbursement
(Leosala, Hizon, Jimenez)

- Third party reimbursement is compensation for services provided by a third party,

rather than the person receiving the services. This is commonly used in any
business, but are most common in the health care industry.

- The patient is the first party, the health care or service provider is the second party
and the third party is an insurance company which are either public or private.
Instead of requiring the patient to pay at the time the facility provides a service, an
insurance company receives the bill.

- Health insurance companies use this system, as do government benefits

programs. Some employers allow their employees to bill particular products and
services to them for third party reimbursement. Health insurance companies
commonly use a network of physicians and other health care providers, for
example. Their clients are expected to try these providers first when seeking care. If they
see a physician out of network,reimbursement may not be provided or it may be much
lower than it would be otherwise.

- Commonly, policies specifically forbid reimbursement for certain things, like elective or
experimental medical procedures in the case of health insurance. People can
usually get a list of approved and disallowed services so they can plan accordingly
in advance and avoid the surprise of an unpaid bill.

HOW IT WORKS

In a third party reimbursement, the patient provides proof of insurance before receiving
services, usually by showing the receptionist an insurance card that includes the name of the

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insurance company and an insurance identification number. After receiving the bill, the third
party will either pay the entire bill, send a partial payment to cover only certain services
or expenses, or refuse the bill if the services are not part of the patient’s insurance
coverage. If this happens, the service provider will then bill the patient for the outstanding
balance.

ADVANTAGES

1. They allow patients access to otherwise expensive medical care for lowered or no
cost. This can help improve wellbeing and longevity.

2. They make sure that medical providers are receiving adequate payment. Without
third-party payments, those providers could lose money due to patients who would be
unable to pay the full cost of medical expenses.

BENEFITS (sama nalang itu sa advantages)

- Third party payers make it easier for patients to pay some of a healthcare bill or
can even cover the entire cost.

- It is beneficial in a way that the third-party payers help individuals to prepare for
potential health related problems and costs associated with that. They mitigate
the effect of those medical expenditures by bearing full or partial health related
expenses.

DISADVANTAGES

1. Healthcare providers will not receive payment for services right away.

2. Added financial aid for medical costs could cause patients to accept unnecessary
medical expenses for an unneeded doctor visit.

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3. Third-party payers can limit who a patient chooses as a provider. This can be tough for a
patient especially if they are needing a specialist.

4. There can be an increased environment for fraud. Costs could be increased since a third
party is taking care of the fees.

Types of Third-Party Reimbursement

a. Philhealth
(Jose, Faeldan)

PhilHealth is a national health insurance program which was established to provide health
insurance coverage and ensure affordable, acceptable, available and accessible health care
services for the Filipinos.

Members can be direct contributors or indirect contributors:

Direct Contributors - Direct contributors refer to those who are gainfully employed and bound by
an employer-employee relationship and are those who have the capacity to pay premiums
● employees with formal employment
● kasambahays
● self-earning
● professional practitioners
● overseas Filipino Workers
● Filipinos living abroad and those with dual citizenship
● Lifetime members
● all Filipinos aged 21 years and above with capacity to pay

Indirect Contributors - all others not included as direct contributors, as well as their qualified
dependents, whose premium are subsidized by the national government including those who
are subsidized as a result of special laws
● Indigents identified by the DSWD

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● Beneficiaries of Pantawid Pamilyang Pilipino Program

● Senior citizens
● Persons with disability
● Sangguniang Kabataan (SK) officials
● Previously identified at point-of-service / sponsored by LGUs
● Filipinos aged 21 years old and above without capacity to pay premiums

Benefits
● Inpatient Benefits
❖ These benefits are paid to the accredited Health Care Institution (HCI) through All
Case Rates
❖ The case rate amount shall be deducted by the HCI from the member’s total bill,
which shall include professional fees of attending physicians, prior to discharge
❖ The case rate amount is inclusive of hospital charges and professional fees of
attending physician
❖ Documents needed: copy of Member Data Record or PhilHealth Benefit Eligibility
Form (PBEF) and duly accomplished PhilHealth Claim Form 1
❖ Where available: all accredited HCIs*
*Different case rate amounts for selected medical conditions are being implemented
when done in Primary Care facilities (PhilHealth Circular 14, s-2013)
❖ Only admissible cases shall be reimbursed
● Outpatient Benefits
❖ Day Surgeries (Ambulatory Or Outpatient Surgeries) Are Services That Include
Elective (Non-Emergency) Surgical Procedures Ranging From Minor To Major
Operations, Where Patients Are Safely Sent Home Within The Same Day For
Post-Operative Care
Payments for these procedures are made to the accredited facility
through All Case Rates
The case rate amount shall be deducted by the HCI from the member’s
total bill, which shall include professional fees of attending physicians,
prior to discharge
The case rate amount is inclusive of hospital charges and professional
fees of attending physician

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Documents needed: copy of Member Data Record and duly accomplished

PhilHealth Claim Form 1
Where available: Accredited Ambulatory Surgical Clinics (ASCs)

❖ Radiotherapy
The case rate for radiotherapy using cobalt is P2,000 per session and
P3,000 per session for linear accelerator
Includes radiation treatment delivery using cobalt and linear accelerator
Claims for multiple sessions may be filed using one (1) claim form for both
inpatient and outpatient radiation therapy
May be availed of even as second case rate (full case rate amount)
45 days benefit limit: One session is equivalent to one day deduction from
the 45 allowable days per year
If procedure is done during confinement, only the total number of
confinement days shall be deducted
Exempted from Single Period of Confinement (SPC) rule (admissions and
readmissions due to same illness or procedure within 90-calendar day
period)
Where available: Accredited HCIs including Primary Care Facilities that
are accredited for the said service

❖ Hemodialysis
The Case Rate for hemodialysis is P2,600 per session
Covers both inpatient and outpatient procedures including emergency
dialysis procedures for acute renal failure
Claims for multiple sessions may be filed using one (1) claim form for both
inpatient and outpatient hemodialysis
May be availed of even as second case rate (full case rate amount)
90 days benefit limit: One session is equivalent to one day deduction from
the 90 allowable days per year
If procedure is done during confinement, only the total number of
confinement days shall be deducted

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The procedure is exempted from Single Period of Confinement rule

(admissions and readmissions due to same illness or procedure within
90-calendar day period)
Where available: All Accredited HCIs – this benefit is no longer restricted
to hospitals and free standing dialysis centers provided that the service is
within their capability as provided for in the DOH license

❖ Outpatient Blood Transfusion

The case rate for outpatient blood transfusion is P3,640 (one or more
units)
Includes Drugs & Medicine, X-ray, Lab & Others, Operating Room
Covers outpatient blood transfusion only
One day of transfusion of any blood or blood product, regardless of the
number of bags, is equivalent to one session
May be availed of as second case rate (full case rate amount)
45 days benefit limit: One session for each procedure is equivalent to one
day deduction from the 45 allowable days per year Exempted from the
SPC rule
Where to avail: All Accredited HCIs

● Z Benefits - include mandatory services for the totality of care that are essential for the
treatment of the condition, hospital services such as accommodation, medicines,
laboratories and professional fees and other services or alternative guideline
recommendations that may be needed by the patient

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● SDG Related

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PhilHealth Partners - Forge partnerships with only the best in the industry to fulfill our mandate of
providing all Filipinos with accessible, available, acceptable and affordable health care services that will
lead to better health outcomes and improved quality of life
● Healthcare Providers - to fulfill our mandate of providing all Filipinos with accessible,
available, acceptable and affordable health care services that will lead to better health
outcomes and improved quality of life
● Employers - partner with employers in the government and private sectors to ensure that all
their employees are provided with social health insurance coverage as mandated by law
● Service Providers - electronic transactions and to help us achieve our goal, we have entered
into partnerships with Health IT Providers for our e-claims and related processes
● Collecting Partners - the services and networks of bank and non-bank institutions to make
premium remittance more convenient for our members and employers. This section provides
a complete list of these partners and their branch locations, and also includes basic
information for collecting agencies that might be interested to partner with us in premium
remittance

b. HMO
(Magnaye, Guevarra)

Health Maintenance Organization (HMO)

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A type of health insurance plan that usually limits coverage to care from doctors who work for or
contract with the HMO. It generally won't cover out-of-network care except in an emergency. An
HMO may require you to live or work in its service area to be eligible for coverage. HMOs often
provide integrated care and focus on prevention and wellness.

How a Health Maintenance Organization (HMO) Works

Health maintenance organizations (HMOs) provide health insurance coverage for a monthly or
annual fee. An HMO limits member coverage to medical care provided through a network of
doctors and other healthcare providers who are under contract with the HMO.These contracts
allow for premiums to be lower than for traditional health insurance since the health providers
have the advantage of having patients directed to them. They also add additional restrictions to
the HMO's members.

Rules for HMO Subscribers

HMO subscribers pay a monthly or annual premium to access medical services in the
organization’s network of providers, but they are limited to receiving their care and services from
doctors within the HMO network. However, some out-of-network services, including emergency
care and dialysis, can be covered under the HMO. Those who are insured under an HMO may
have to live or work in the plan's network area to be eligible for coverage. In cases where a
subscriber receives urgent care while out of the HMO network region, the HMO may cover the
expenses. But HMO subscribers who receive non-emergency, out-of-network care have to pay
for it out-of-pocket.

Difference Between an HMO and Health Insurance?

· Coverage under an HMO is generally pretty restrictive and comes at a lower cost to insured
parties. Traditional health insurance, on the other hand, charges higher premiums, higher
deductibles, and higher co-pays. But health insurance plans are much more flexible. People
with health insurance don't need to have a primary care physician to outline treatment.
Health insurance also pays some of the costs for out-of-network providers.

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Advantages of HMOs

· The first and most obvious advantage of participating in an HMO is the low cost. You'll pay
fixed premiums on a monthly or annual basis that are lower than traditional forms of health
insurance. These plans tend to come with low or no deductibles and your co-pays are
generally lower than other plans. Your out-of-pocket costs will also be lower for your
prescription. Billing also tends to be less complicated for those with an HMO.

· There's also a very good likelihood that you'll have to deal with the insurer itself. That's
because you have a primary care doctor you must choose from who is responsible to
manage your treatment and care. This professional will also advocate for services on your
behalf. This includes making referrals for specialty services for you.

· The quality of care is generally higher with an HMO. The reason is that patients are
encouraged to get annual physicals and to seek out treatment early.

Disadvantages of HMOs

· If you're paying for an HMO, you're restricted on how you can use the plan. You'll have to
designate a doctor, who will be responsible for your healthcare needs, including your
primary care and referrals. This doctor, though, must be part of the network. This means you
are responsible for any costs incurred if you see someone out of the network, even if there's
no contracted doctor in your area.

· You'll need referrals for any specialists if you want your HMO to pay for any visits. So if you
need to visit a rheumatologist or a dermatologist, your primary doctor must make a referral
before you can see one for the plan to pay for your visit. If not, you're responsible for the
entire cost.

· There are very specific conditions that you must meet for certain medical claims, such as
emergencies. For instance, there are usually very strict definitions of what constitutes an
emergency. If your condition doesn't fit the criteria, then the HMO plan won't pay.

c. Health Insurance

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(Eusebio K., Grepalda)

Health insurance is a form of financial service that provides financial security in the midst of an
illness or when health calls for it. It covers medical and surgical costs, either by preventive or
corrective means. In most cases, individuals who have health insurance literally pay nothing
after a procedure is done.
● Insurers use the term <provider= to describe a clinic, hospital, doctor, laboratory,
healthcare practitioner, or pharmacy that provides treatment for an individual’s condition.
● The <insured= is the owner of the health insurance policy or the person with the health
insurance coverage.
In order to enjoy such benefits, the insured pays a premium. While health insurance is
mandatory in the country through Philhealth, its coverage leaves a lot to be desired.
Private health insurance gives access to more comprehensive private healthcare networks,
offering a lot more than HMOs do. In the Philippines, private health insurance is usually bought
by the individual voluntarily. There are some companies that provide this type of insurance to
their employees.
Premiums can be steep and are fully paid by the insured. Immediate family members can be
also insured on the policy at an additional cost. Private insurers offer many benefits and
features. Their facilities are usually at par with international standards, and some even extend
their policy outside the country. The benefit of this insurance can include the following:
● Inpatient/outpatient services
● Hospitalization and surgical assistance
● Cash assistance for loss of income due to accident/illness
● Other ancillary services such as laboratory tests and medication
● Bigger cash compensation depending on the illness

Benefits of health insurance

One of the most compelling reasons to have insurance is to avoid becoming bankrupt while
caring for your health. Our health deteriorates as we age, whether we like it or not, and even if
you've amassed enough wealth to finance a year in the hospital, that's still not a solid financial
and retirement plan.

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Getting health insurance may not provide you with a lump sum of money to spend on your
health all of the time, but it will at the very least cover all of the care and services that you will
need when the time comes, such as the following:
1. Inpatient Care
- Inpatient care refers to the treatment of a patient who requires hospitalization. Immediate
care, specialized procedures, and facilities are required, which the patient or family
cannot provide outside of the hospital. Only when a patient is admitted to the hospital or
when it is documented in the hospital's admission book is he regarded an inpatient. In
most cases, the following perks are included in inpatient benefits.
1.) Hospitalization
2.) Mental Health
3.) Rehabilitation
4.) Ambulance
5.) Medicine
6.) Laboratory tests
7.) Pediatrics
2. Outpatient Care
- Outpatient care varies from inpatient care in that a patient visits a hospital and seeks
medical attention, but the patient is not admitted since the ailment can be managed at
home or at a doctor's office. The attending physician will usually offer or prescribe
medicine to the patient to prevent the illness from recurring. The following advantages
come with outpatient care.
1.) Wellness
2.) Preventive Care
3.) Laboratory tests
4.) Annual Physical Examinations (APE)
3. Optional Benefits
- These are advantages that aren't generally included in health insurance plans. You will
have to pay an additional fee to receive some of these benefits. Optional advantages are
usually the most popular, although they are distinct from recovery from a catastrophic
illness. From a business standpoint, including these is impractical unless more people
request them. Maternity benefits are one example of this scenario, where a provider
would need to hire more than 25 females to qualify.
1.) Dental

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2.) Optical
3.) Maternity

Cost of health insurance in the Philippines

The cost of health insurance actually varies, for the case of PhilHealth it’s depending on the
salary. As for the private ones, age will be a significant factor.

d. Financial assistance from private government organization (e.g Green card of

Laspinas City)
(Gyenes, Gealon)

● The health-care system of Las Piñas is known as "Green Card." Every lawful resident is
entitled to subsidized hospitalization at PhP 30,000. Minor surgery and confinement are
included in the hospitalization package.
● Vergel "Nene" Aguilar, the mayor of Las Piñas, is instrumental in bolstering the city
government's hospitalization program, which assists those in need of financial aid due to
the high expense of medical care. Health care is now more accessible to Las Piñas
residents with the Green Card.
● In addition to Las Piñas Doctor's Hospital, San Juan de Dios Hospital, Philippine General
Hospital, and Las Piñas City Medical Center, Mayor Imelda T. Aguilar and Vice Mayor
April Aguilar-Nery announced that the Perpetual Help Medical Center-Las Piñas is the
latest medical facility to be accredited by the city's Green Card Program.
● The Mayor's Office, City Health Office, and City Social Welfare and Development Office
oversee the Green Card hospitalization support program. Green Card holders now
number around 200,000.

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● The green card contains personal information of the principal member and his or her
dependents. Each individual enrolled into the green card either as principal or dependent
is entitled to the hospitalization program each year.

Requirements that you will need to get a green card:

1. Photocopy of Voter Registration Record (VRR)

2. Photocopy of Certificate of Marriage, if married.
3. Photocopy of Birth Certificate of unmarried children.
4. Photocopy of Voters Registration Record (VRR) / Voter’s ID (VIN) of unmarried children 21
yrs old and over.
5. Barangay Certificate / Clearance (for Greencard)
6. 2 pcs. Identical 1 X 1 photo taken within (1) year
7. Photocopy of Community Tax Certificate (CEDULA)
- Gyenes

Benefits of Green Card:

1. They pay up approximately 30,000 of said restricted patient ’s overall medical bill.
2. Some Registered Senior Citizens more than 5 thousand of them are beneficiaries who
received 1500 monthly allowance from the City Government.
3. It is said that Every Monday and Tuesday Seniors Citizen can enjoy and watch free
movies in a selected Malls in Las Piñas.
4. Senior Citizens were given a 5 percent discount when purchasing manufactured
commodities in the market like Rice, Meat and Vegetables.

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5. Senior Citizens there also were given a discount when buying their Maintenance medication
for their Health.

Advantage of Green Card:

1. They can save money for their family since their Older Family member is beneficiary of the
Green card.
2. For the Mother and Child they were ensure to have a comfortable healthcare which can
decrease the burden to the both of them especially to the Hospital bills that they need to pay.
3. These have made a significant contribution towards the democracy of medical services
inside the city as well as the improvement of citizens' standard of living.
4. All Las Piñas citizens can join as long as you have voters ID like how you registered
yourselves when in comes to Voting for Politics.

DisAdvantage of Green Card:

1. Some Netizens will take advantages to the benefits of the green card which is should be
prevented because not all the time netizens will depend to the Government.
2. Must comply with the residency requirement before owning it.
3. Some Netizens might be given a conditional before obtaining the green card.
4. Your green card should always be carried from you at any instances which might be a
burden to you.

- Gealon

REFERENCES

McMahon, M. (2022). What is Third Party Reimbursement?. Retrieved from

https://www.smartcapitalmind.com/what-is-third-party-reimbursement.htm#:~:text=Third%20part
y%20reimbursement%20is%20compensation,company%20pays%20the%20service%20provide
r.

Lohrey, J. (2017). What Is Third-Party Reimbursement?. Retrieved from

https://bizfluent.com/info-12159541-thirdparty-reimbursement.html.

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Amazing Health Care Insurance Consultants (2021). What is Third Part Payment in
Healthcare?. Retrieved from
https://www.amazinghealthcareconsultants.com/third-party-payment/.

About Us | PhilHealth. (n.d.). PhilHealth. https://www.philhealth.gov.ph/about_us/

PHILHEALTH CIRCULAR (No.2019–0009). (2019, October). Phiippine Health nsurance

Corporation.https://www.philhealth.gov.ph/circulars/2019/circ2019-0009.pdf

PhilHealth’s Z Benefits For Catastrophic Illnesses Launched | PhilHealth. (n.d.).

PhilHealth.https://www.philhealth.gov.ph/news/2012/z_benefits.html#:%7E:text=The%20packag
e%20is%20called%20’Z,the%20package%20will%20be%20addressing.

Las Pinas Our Home (n.d)

.Health Care: Green Card. Retrieved from
https://www.laspinascity.gov.ph/services/3/health-care-green-card.

Ellalyn, DV. & Noriega, R. (2019).Las Piñas partners with Perpetual Help Medical Center.
Retrieved from
https://mb.com.ph/2019/07/10/las-pinas-partners-with-perpetual-help-medical-center/.

https://www.alliance-healthycities.com/PDF/AFHC_Directory_2014/08Philippines_AFHC2014Dir
ectory_01112014.pdf

James, L. (n.d.). Las Piñas hospital accredits LGU Green Card. Retrieved from
https://metronewscentral.net/las-pinas/metro-cities/las-pinas-hospital-accredits-lgu-green-card.

Hayes, A. (2022). What Is a Health Maintenance Organization (HMO)?. Retrieved from

https://www.investopedia.com/terms/h/hmo.asp.

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