UPGRADING THE AMOUNT OF REIMBURSEMENT FOR PROFESSIONAL FEES OF PHYSICIANS FOR EC MEDICAL BENEFIT CLAIMS IN THE PRIVATE SECTOR
(Pending upon approval of the President of the Republic of the Philippines)
WHEREAS, Art. 183 (formerly 177), paragraph (e) of P.D. No. 626, as amended, partly reads:
“Art 183 (formerly 177) (e) … the Commission may upgrade benefits and add new ones subject to the approval of the President; and Provided, Further, That the actuarial stability of the State Insurance Fund (SIF) shall be guaranteed; Provided, Finally, that such increases in benefits shall not require any increase in contribution…”
WHEREAS, there is a need to continually enhance benefits under the Employees’ Compensation Program (ECP) to make them more responsive to the welfare and development needs of Persons with Work-Related Disabilities (PWRDs);
WHEREAS, the Commission has prescribed expense schedules for the reimbursement of EC medical benefits such as professional fees for physicians for ward visits, laboratory and diagnostic examinations, professional rates for surgical and medical procedures, medicines, hospital ward accommodation, hemodialysis and physical therapy sessions;
WHEREAS, Executive Order No. 135, dated April 23, 2013, provided, among others, the increase in the reimbursable amount of professional fees for physicians in the public sector to equalize it with the private sector;
WHEREAS, the present reimbursable amount for professional fees for physicians for daily ward visits for both private and public sectors is as follows:
| General Practitioner | Specialist | |
| Initial visit
Succeeding visit |
Php100
Php 80 |
Php 150
Php 100 |
WHEREAS, given the continuously rising costs of health care, the ECC reviewed the present EC policy on amount of reimbursement for professional fees of physicians taking into consideration the reimbursement policies for professional fees of physicians of the Philippine Health Insurance Corporation prior to the implementation of the case rate system and as well as the reimbursement schedule of health maintenance organizations (HMOs);
WHEREAS, based on the review, the ECC proposed the following options to increase the present amount of reimbursement for professional fees of physicians in the private sector:
| General Practitioner | Specialist | ||||||||
| Option 1 | Option 2 | Option 3 | Option 1 | Option 2 | Option 3 | ||||
| A. Daily Ward Visits (In Php) | |||||||||
| Per Day | 200 | 300 | 400 | 400 | 500 | 600 | |||
| Maximum Per Confinement | 800 | 1,200 | 1,600 | 1,600 | 2,000 | 2,400 | |||
| B. ICU/CCU Ward (In Php) | |||||||||
| Per Day | 400 | 600 | 800 | 800 | 1,000 | 1,200 | |||
| Maximum per Confinement | 1,600 | 2,400 | 3,200 | 3,200 | 4,000 | 4,800 | |||
| C. Out-patient Consultation (In Php) | |||||||||
| Per consultation | 200 | 300 | 400 | 400 | 500 | 600 | |||
| D. Consultation for pre-procedure medical evaluation (Out-patient and In-patient) (In Php) | |||||||||
| Routine (Per pre-procedure medical evaluation) | 400 | 600 | 800 | 800 | 1,000 | 1,200 | |||
| With Medical Indication (Per pre-procedure medical evaluation) | 800 | 1,000 | 1,200 | 1,000 | 1,200 | 1,400 | |||
| E. Intra-operative Monitoring (In Php) | |||||||||
| General Practitioner | Specialist | ||||||||
| Option 1 | Option 2 | Option 3 | Option 1 | Option 2 | Option 3 | ||||
| 800 | 1,000 | 1,200 | 1,000 | 1,200 | 1,400 | ||||
WHEREAS, the EC Secretariat requested the SSS to conduct an actuarial study to determine the viability of the State Insurance Fund to finance an increase in the amount of reimbursement for professional fees of physicians;
WHEREAS, the result of the actuarial study by the SSS concluded that the Fund remains viable and will last beyond 2080 even after the implementation of any of the three proposed options on the increase in the amount of reimbursement for professional fees of physicians notwithstanding the other simultaneous increases in EC benefit and that the increase does not necessitate additional EC contribution or funding;
WHEREAS, after due deliberation taking into consideration the SSS actuarial study and the ECC review of its existing policy on the amount of reimbursable professional fee for physicians, the members of the Commission agreed to increase the amount of reimbursement for professional fees of physicians to the following maximum amounts:
| General Practitioner (Php) | Specialist (Php) | |
| A. Daily Ward Visits | ||
|
per Day |
400 |
600 |
|
Maximum Per Confinement |
1 ,600 |
2,400 |
| B. ICU/CCU Ward | ||
|
Per Day |
800 |
1 ,200 |
|
Maximum Per Confinement |
3,200 |
4,800 |
| C. Out-patient Consultation | ||
|
Per consultation |
400 |
600 |
| D. Consultation for pre-procedure medical evaluation (Out-patient and In-patient) | ||
|
Routine (Per pre-procedure medical evaluation) |
800 |
1 ,200 |
|
With Medical Indication (Per pre-procedure medical evaluation) |
1 ,200 |
1 ,400 |
| E. Intra-operative Monitoring |
1 ,200 |
1 ,400 |
NOW THEREFORE, ON MOTION DULY MADE AND SECONDED
This Commission RESOLVES as it hereby RESOLVED to upgrade the amount of reimbursement rate for professional fees of physicians for EC medical claims in the private sector to the following maximum amounts:
| General Practitioner (Php) | Specialist (Php) | |
| A. Daily Ward Visits | ||
|
per Day |
400 |
600 |
|
Maximum Per Confinement |
1 ,600 |
2,400 |
| B. ICU/CCU Ward | ||
|
Per Day |
800 |
1 ,200 |
|
Maximum Per Confinement |
3,200 |
4,800 |
| C. Out-patient Consultation | ||
|
Per consultation |
400 |
600 |
| D. Consultation for pre-procedure medical evaluation (Out-patient and In-patient) | ||
|
Routine (Per pre-procedure medical evaluation) |
800 |
1 ,200 |
|
With Medical Indication (Per pre-procedure medical evaluation) |
1 ,200 |
1 ,400 |
| E. Intra-operative Monitoring |
1 ,200 |
1 ,400 |
RESOLVED FURTHER, that all previous Rules and Regulations which are inconsistent with this Resolution are hereby repealed or modified accordingly;
RESOLVED FINALLY that a copy of this Resolution shall be transmitted to the Office of the President of the Republic of the Philippines for approval and that upon approval of the Office of the President, the corresponding Executive Order shall be published in a newspaper of general circulation for effectivity purposes.
DONE, this 25th day of October 2017, in Quezon City, Philippines .
(SGD.) CIRIACO A. LAGUNZAD
Chairperson-Alternate
Department of Labor and Employment
(SGD.) RIZALDY T. CAPULONG
Member-Designate
Social Security System
(SGD.) DIONISIO C. EBDANE, JR.
Member-Designate
Government Service Insurance System
(SGD.) CARLITO P. ROBLE
Member
Employees’ Sector
(SGD.) STELLA ZIPAGAN-BANAWIS
Member
Employees’ Compensation Commission – Secretariat