ORDINANCE NO: 2024-589 Sponsored by: Committee on Health and Social Services "AN ORDINANCE PROVIDING GUIDELINES IN THE DISPOSITION OF PHILHEALTH REIMBURSEMENT OF PROFESSIONAL FEE AND PHILHEALTH SHARE FOR THE HEALTH CARE FACILITY OF PAGADIAN CITY INFIRMARY AND FOR OTHER PURPPOSES" WHEREAS, Section 34-A of the RA 10606 entitled "An Act Amending Republic Act No. 7875, otherwise known as the "National Health Insurance Act of 1995" states that "All payments for professional services rendered by salaried public providers shall 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 retained by the individual facility in which services were rendered and for which payment was made. Such revenues shall be used to primarily defray operating costs other than salaries, to maintain or upgrade equipment, plant or facility, and to maintain or improve the quality of service in the public sector."; WHEREAS, Fee-for-service has been replaced by Case-Based Payment scheme as the main Provider Payment Mechanism of PhilHealth.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 Phil Health Circular (PC) No. 11-A and 11-B s. 2011, this was expanded to the All Case Rate Policy as per PC No.31 s. 2013. In addition, PC No. 35 s. 2013 has also set the rates of 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; WHEREAS, 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 of the PF reimbursed by PhilHealth throughout government hospitals. Thus, in the face of all the recent changes in policy as well as the non-uniform sharing of PF among HCIs, the following guidelines are issued to ensure that these provisions are harmonized and effectively implemented; NOW, THEREFORE, BE IT ORDAINED by the Sangguniang Panlungsod (14th City Council) of Pagadian City, that: SECTION 1. TITLE. - This Ordinance shall be known as "AN ORDINANCE PROVIDING GUIDELINES IN THE DISPOSITION OF PHILHEALTH REIMBURSEMENT OF PROFESSIONAL FEE AND PHILHEALTH SHARE FOR THE HEALTH CARE FACILITY OF PAGADIAN CITY INFIRMARY AND FOR OTHER PURPPOSES". SECTION 2. OBJECTIVES. - This Ordinance aims to ensure fair disposition of professional fee to Health Care Providers of Pagadian City Infirmary by setting the rules and fixing the rate distribution among Health Care Workers and the right disposition of PhilHealth share for the Heath Care facility. SECTION 3. SCOPE AND COVERAGE. - These guidelines shall cover all salaried Health Care Providers of Pagadian City Infirmary. SECTION 4. DEFINITION OF TERMS. - For purposes of this Ordinance, the following words and/or terms shall be construed to mean, as follows: 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 Doctor - a duly licensed Doctor of Medicine and Doctor of Dental Medicine. 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. Health Care Institution (HCI) - refers to health facilities that are PhiiHealth-accredited which includes, among others, hospitals, ambulatory surgical clinics, TB-DOTS, freestanding dialysis clinics, primary care benefits facilities, and maternity care package providers. SECTION 5. GENERAL GUIDELINES. All doctors and non-physician health workers are entitled to a share of the pooled funds regardless of employment status. Policies and procedures on the manner and frequency of distribution of the pooled funds shall be formulated and enforced by the HCI. The HCI shall withhold the expanded withholding tax as 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 Government Money Payment (GMP), if applicable. SECTION 6. SPECIFIC GUIDELINES Pooling of all PF reimbursements from PhilHealth shall be done to all cases admitted in the designated PhilHealth beds/wards of the Infirmary. All Doctors and non-physician health workers who are full-time, permanent, temporary, casual, contractual or from the medical pool are entitled to a share from the "pooled funds" including those: Attending seminars/workshops, conferences and/or lectures as covered by corresponding Department Orders and/or Hospital Orders; On approved vacation, sick and other allowable leaves applicable under existing Civil Service Laws; On study leave or grant provided such entitlement shall be limited to a maximum of six (6) months and; Those who are detailed, in-service or lateral entry training in the hospital where they are serving. The following personnel shall not be entitled to a share from the pooled funds: a. Those who are meted with disciplinary measures such as suspension or fine; b. Those who are on leave without pay; c. Those who are detailed in other offices or institutions. Only updated PhilHealth-accredited doctor/s shall be included under the "Medical Doctors" group, otherwise, the non-updated PhilHealth-accredited doctor/s shall be treated to belong to the "Other Health Professional category in the sharing of Professional Fees. (PhilHealth Circular No. 28, s. 2012, III. B) For newly hired workers, they shall be entitled to a share in the Common Fund after three (3) months from the date of their assumption. Likewise, for the outgoing personnel, he/she shall not be entitled to a share in the Common Fund after three (3) months from his/her last day in service. All other issues that may arise involving the utilization and sharing of this Common Fund shall be subject to the discretion of the Chief of Hospital, as the head of the facility. Proper accounting of the disbursement of the Common Fund shall be established by the facility concerned. SECTION 7. GUIDELINES IN THE DISTRIBUTION OF PROFESSIONAL FEES FROM THE PHILIPPINE HEALTH INSURANCE CORPORATION (PHIC) REIMBURSEMENT: The Pagadian City Infirmary shall create a "Common Fund" under a separate Trust Fund account where all professional fees for services rendered to PhilHealth patients shall be pooled and distributed among salaried health personnel. All Salaried Health Personnel refers not only to Regular Employees but also to Contract of Service (Cos) and Job Orders (JOs) shall be included in the distribution on the reason that these non-regular employees are also health personnel doing the same work and the same number of hours as the regular employees, and are also exposed to same degree of hazards in their working environment as those regular employees and observe and follow the same policies as those regular employees, yet, receive only monthly salaries with no other allowances unlike that of regular employee when in fact they have also greatly contributed to the total productivity and performance of Pagadian City Infirmary. Salaried Health Personnel whether regular, COs or JOs are classified into two categories: Category A - Non-Physician Health Professional involved in patient care, rendering service at the Nursing Department, Laboratory, Pharmacy, Radiology and Dental Clinic. All Section Heads are included in this category being primarily responsible for the operations of their respective section with great impact on the totality of infirmary services, Category B - Non-Health Professional who are not in direct contact with patients during their regular duty like the Medical Social Workers, Administrative Staff, Accounting, Supply, Medical Records, Building Maintenance, Transport, Admitting, Billing Unit, Cash, Dietary, Housekeeping, and PhilHealth Unit Staff. Above classification Other Health Professional Staff of the Facility and Non-Health Professional Staff by category shall be subjected for review after three (3) months of implementation in order to come up with the most equitable sharing scheme for the best interest of the hospital personnel. Sharing amount in each category shall be uniform provided that there is no significant gap in peso sharing individually for the above groupings. The following amount is hereby set for a more comprehensive application of the gaps per sharing period: Category A as against Category B using the value agreed by management, i.e., 300, 500, or 1000. Such pooled professional fees shall be divided equally as 50% for the Physicians and 50% for Other Health Professional Staff of the Facility and Non-Health Professional Staff. Formula for Individual Computation: The computation in apportioning the 50% portion of the reimbursement of Professional Fees among the other Health Professional Staff of the Facility and Non-Health Professional Staff are outlined below: STEP 1 Determine the Average Amount of Reimbursement (AAR) to be received by all employees AAR = Amt of Reimbursement Total No. of Employees STEP 2 Compute the variance between categories using the value agreed by management, i.e., 300, 500, or 1000, by employing the formula given: Cat A= AAR + Value Agreed Cat B= AAR - Value Agreed STEP 3 Determine the Reimbursement Amount per Category (RAC) by multiplying the amount computed in Step 2 per category name by the number of employees in that category. RAC = Category Name X No. of employee per category STEP 4 In the event that there is a deficit (, i.e., the total amount of reimbursement is less that the total computed amount in all categories in Step 3, the same shall be prorated based on the number of employees per category name over the total number of employees. Pro-rated deficit (PRD) = D * No. of employees per category / Total no. of employees in all categories. STEP 5 Deduct the Pro-Rated Deficit (PRD) from the total amount of reimbursement per category name computed under Step 3 to get the Final Amount per Category (FAC) FAC = RAC - PRD STEP 6 Determine the individual amount (IA) to be received by dividing the amount computed in Step 5, FAC, by the total number of employees per category. IA = FAC / No. of employees per category Prior to sharing, the hospital management shall convene to discuss the Value Agreed by Management and place it in writing with employees signatures attesting what was agreed during the meeting. SECTION 8. DISPOSITION OF PHILHEALTH SHARE FOR HEALTH CARE FACILITY. The facility share shall be used for the following; Procurement of essential and lifesaving drugs and medicines, medical, dental and laboratory supplies; Maintain or upgrade equipment, plant or facility; and Maintain or improve the quality of service. SECTION 9. SEPARABILITY CLAUSE - If any part of this Ordinance is held unconstitutional or invalid, the other provisions not otherwise affected shall remain in full force and effect. SECTION 10. REPEALING CLAUSE - All other issuances inconsistent herewith are hereby modified or repealed accordingly. SECTION 11. EFFECTIVITY-This Ordinance shall take effect immediately after fifteen (15) days from posting thereof in at least two (2) conspicuous places in the City. ENACTED AND APPROVED by the Sangguniang Panlungsod (14th City Council) during its 94th Regular Session on 16 October 2024 at the SP Session Hall, 4th Floor City Commercial Center (C3), Santiago District, Pagadian City.