In the Philippine healthcare system, the Philippine Health Insurance Corporation (PhilHealth) serves as the primary implementer of the Universal Health Care (UHC) Act (Republic Act No. 11223). Navigating the intersection of patient rights, hospital billing, and PhilHealth coverage requires a clear understanding of the legal frameworks governing benefit packages and the limitations of financial risk protection.

I. The Legal Mandate: Universal Health Care and PhilHealth

Under Republic Act No. 11223, every Filipino citizen is automatically enrolled in the National Health Insurance Program. The law categorizes members into two groups:

Direct Contributors: Those who pay premiums (e.g., employees, self-employed, OFWs).
Indirect Contributors: Those whose premiums are subsidized by the government (e.g., indigents, senior citizens, PWDs).

PhilHealth is mandated to provide a comprehensive benefit package that includes inpatient, outpatient, and emergency care. However, this "comprehensive" coverage is subject to specific Case Rates and Benefit Limits defined by the Corporation.

II. The Case Rate System

The most critical aspect of hospital billing in the Philippines is the All-Case Rate (ACR) policy. Unlike a "percentage-based" reimbursement, PhilHealth generally pays a fixed amount for a specific medical condition or surgical procedure.

How Case Rates Work

When a patient is discharged, the hospital identifies the primary diagnosis or procedure. PhilHealth provides a predetermined amount that covers:

Professional fees (PF) of the attending physicians.
Hospital charges (room and board, laboratory tests, medicines, and operating room fees).

Important Note: The case rate is split, usually with 30% allocated to Professional Fees and 70% to Hospital Charges. If the hospital charges exceed the 70% allocation, or the PF exceeds the 30% allocation, the patient may be required to pay the difference, unless covered by the "No Balance Billing" policy.

III. No Balance Billing (NBB) Policy

Under PhilHealth Board Resolution No. 2489, s. 2019, the No Balance Billing (NBB) policy dictates that certain "vulnerable" members shall not pay any fees over and above the PhilHealth package when admitted to government (public) facilities.

Who is covered by NBB?

Indigent members and Sponsored members.
Senior Citizens and PWDs.
Kasambahays.
Lifetime members.

Limitations of NBB

NBB generally applies only to Ward Accommodation in government hospitals. If an NBB-eligible patient opts for a private room or is admitted to a private hospital, the NBB policy typically does not apply, and "Balance Billing" (paying the excess) occurs.

IV. Coverage Limits and Out-of-Pocket Expenses

For members not covered by NBB, or those seeking care in private institutions, several factors limit the extent of PhilHealth coverage:

1. Single Period of Confinement

PhilHealth follows the "Single Period of Confinement" rule, where admissions for the same illness within a 90-day period are treated as a single case. If a patient is re-admitted for the same condition within this window, the benefit may no longer be available or will be significantly reduced.

2. Benefit Caps on Specific Items

While the Case Rate is a lump sum, hospitals must still reflect the PhilHealth deduction on the Statement of Account (SOA). If the cost of specific high-value drugs or specialized supplies exceeds the total Case Rate, the patient bears the "out-of-pocket" cost.

3. Professional Fee (PF) Limits

In private settings, doctors may charge fees higher than the PhilHealth PF allocation. In such instances, the PhilHealth portion is deducted from the doctor’s bill, and the patient pays the "top-up."

V. The Statement of Account (SOA) and Transparency

Under the Department of Health (DOH) and PhilHealth regulations, hospitals are legally required to provide a transparent Statement of Account. This document must clearly show:

The total actual charges.
The specific PhilHealth deduction (Case Rate).
Any discounts (e.g., Senior Citizen or PWD discounts under RA 9994 and RA 10754).
The remaining balance to be paid by the patient.

The Sequence of Discounts

In the Philippines, the legal hierarchy of billing deductions is:

PhilHealth Benefit (Deducted first from the total bill).
Mandatory Discounts (Senior Citizen/PWD discounts are applied to the remaining balance after the PhilHealth deduction).

VI. Legal Recourse and Accountability

Patients have the right to contest billing discrepancies. If a hospital refuses to deduct PhilHealth benefits despite the submission of proper requirements (e.g., Member Empowerment Form, CSF), or if a public hospital violates the NBB policy, the member may file a complaint with:

The PhilHealth Complaints Steering Committee.
The Health Facilities and Services Regulatory Bureau (HFSRB) of the DOH.

Failure of a healthcare provider to comply with these benefit guidelines can lead to administrative fines, suspension of accreditation, or revocation of the hospital’s license to operate.