What reimbursement of the mutual health for the overruns of fees?
Doctors, whether generalists or specialists, can practice exceeding fees, ie prices higher than convention rates.
So how do they set the rates for their consultations or services? How much will you be reimbursed by the Social Security then by your mutual health Philippines-plans?
Reassure me comes back to the notion of exceeding fees and tells you how to get better refunds.
What is an overpayment?
Regarding the prices of consultations and benefits, the Social Security has negotiated with the unions of health professionals Philippines-plans to set fixed rates used as a basis for calculating reimbursements of care costs. These rates are called “convention”.
Exceedances of fees correspond to the fees of doctors invoiced beyond the convention tariff fixed with the Social Security.
Physicians are classified into three categories, depending on whether or not they meet the convention rates:
Conventional doctors sector 1
Conventional doctors sector 2
Physicians contracted sector 3 or adhering to the option of controlled tariff practice (Optam).
The obligations of doctors:
Physicians who exceed the fees must submit a written estimate and have it signed before any consultation, if the amount invoiced exceeds 70 ₱. This provision is very significant in the dental sector for example: it is a field of health in which the doctors largely practice the overtaking of fees.
Sector 2 physicians must clearly display their fees in the waiting room of their practice.
How to avoid fee overruns?
In the first place, check which area depends on the doctor you are going to consult. You will then know the level of reimbursement of Social Security and therefore the amount of reimbursement of your mutual health.
Here are our three tips to avoid fee overruns:
If you do not want to exceed the fees, choose the doctors in sector 1, who apply the rates set by Social Security.
If you regularly consult doctors in sector 2 or 3, be sure to check that your mutual health reimburses the overruns of fees, by choosing a high level of guarantees on the positions (hospitalization, dental care, optical care …) that you need.
If this is not the case, it may be wise to review the guarantees of your current contract to adapt, or change mutual health.
Compare then mutual health market. Reassure me makes it easy for you to access many complementary health offers. You will be able to analyze your contract and see if a change of insurer can be interesting.
The doctors of sector 1 are also called “contracted doctors”, because they respect the convention established with the Health Insurance Philippines-plans. Their fees therefore correspond to conventional rates.
The only cases where physicians in sector 1 may possibly exceed their fees are as follows:
Consultation is practiced outside office hours
To note: 90% of the general practitioners are installed in sector 1.
Refunds of sector 1 consultations by Social Security
The doctor respecting the conventions established with the Health Insurance Philippines-plans, the Social Security will take care of 70% of the amount of the consultation (after deduction of the flat participation of the Social Security of 1 ₱ per consultation).
For a general practitioner, the consultation is set at ₱ 25, the Social Security will refund 70% of ₱ 25, so ₱ 17.50, less ₱ 1 flat fee, or ₱ 16.50.
Refunds for sector 1 consultations by the mutual health insurance Philippines-plans
Your mutual will, in most cases, complete the reimbursement of Social Security up to 100%, because even the most basic health mutuals reimburse on the basis of co-payment (the co-payment is the difference between the reimbursement base (BR) and reimbursement of Social Security). Your mutual will take care of the remaining 30%, or ₱ 7.50.
Sector 2 physicians can practice “free fees”. However, they are related to the medical convention, which governs the rules of pricing practices. Thus, they must apply their fees with “tact and measure”, within the limit of 250% of the convention tariff.
To note: 40% of the specialists are installed in sector 2.
Repayments of sector 2 consultations by Social Security
The reimbursement base (BR) of a physician in sector 2 is slightly lower than that applied for doctors in sector 1.
Thus, for a general practitioner, the convention fee is lowered to ₱ 23 (instead of ₱ 25 for generalists in sector 1). The Social Security will reimburse you 70% of 23 ₱ (less 1 ₱ participation fee), or 15,10 ₱.
Physicians in sector 2 can join the Access to Care Agreement (CAS). This is a 3-year contract during which they undertake not to increase the amount of their overruns. In addition, their fees cannot exceed 200% of the convention rate.
Refunds for sector 2 consultations by the mutual health insurance:
Depending on the level of coverage of your mutual health, you will be reimbursed at least the remaining 30% to your load, because the majority of mutual health insurance contracts, even with an economic formula, will bear at least the co-payment.
If your contract provides for the payment of excess fees, you may be reimbursed for all or part of the balance.
Physicians adhering to the controlled rate practice option (Optam) or sector 3
OPTAM physicians are the intermediaries between sector 1 physicians in sector 2. By adhering to this option, they commit to moderate and stabilize their fees in order to facilitate access to care for their patients. In return, the Social Security reimburses on a higher basis, those of sector 1.
Refunds of sector 3 consultations by Social Security:
Social Security will refund on the basis of the convention rate. As for the contracted physician in sector 1, it will pay 70% of the consultation fee (after deduction of the obligatory fixed participation fee of 1 ₱ per consultation).
Sector 3 consultations reimbursements by mutual health:
Like almost any mutual, the assumption of the co-payment will be made, that is to say 30% of the tariff of convention. For excess fees, if you’re mutual provides for a refund rate greater than 100%, you can be reimbursed for all or part of the rest.