Article 85Labor and Agrarian Laws and Social Legislation, p. 85

LABOR LAWS AND SOCIAL LEGISLATION SPECIAL LAWS AND IMPLEMENTING RULES AND REGULATIONS

(Amendment to R.A. No. 7875, Republic Act No. 9241,

[February 10, 2004], further amended by National Health

Insurance Act of 2013, Republic Act No. 10606, [June 19,

2013])

SECTION 33. Minimum Requirements for Accreditation . —

The minimum accreditation requirements for health care

providers are as follows:

a) human resource, equipment and physical structure in

conformity with the standards of the relevant facility, as

determined by the Department of Health;

b) acceptance of formal program of quality assurance and

utilization review;

c) acceptance of the payment mechanisms specified in

the following section;

d) adoption of referral protocols and health resources

sharing arrangements;

e) recognition of the rights of patients; and

f) acceptance of information system requirements and

regular transfer of information.

SECTION 34. Provider Payment Mechanisms . — The

following mechanisms for public and private providers

shall he allowed in the Program:

(a) Fee-for-service payments — payments made by the

Corporation for professional fees or hospital charges, or

both, based on arrangements with health care providers.

This fee shall be based on a schedule to be established by

the Board which shall be reviewed periodically but hot

less than every three (3) years;

(b) Capitation of health care professionals and facilities, or

networks

of

the

same

including

HMOs,

medical

cooperatives, and other legally formed health service

groups;

(c) Case-based payment;

(d) Global budget; and

(e) Such other provider payment mechanisms that may

be determined and adopted by the Corporation.

Subject to the approval of the Board, the Corporation may

adopt

other

payment

mechanism

that

are

most

beneficial to the members and the Corporation.

Each

PhilHealth

local

office

shall

recommend

the

appropriate payment mechanism within its jurisdiction

for approval by the Corporation. Special consideration

shall be given to payment for services rendered by public

and private health care providers serving remote or

medically underserved areas.

(National Health Insurance Act of 2013, Republic Act No.

10606, [June 19, 2013])

SECTION 34-A. Other Provider Payment Guidelines. — No

other fee or expense shall be charged to the indigent

patient,

subject

to

the

guidelines

issued

by

the

Corporation.

All

payments

for

professional

services

rendered

by

salaried public providers shall be allowed to 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.

(National Health Insurance Act of 2013, Republic Act No.

10606, [June 19, 2013])

SECTION 35. Fee-for-service Payments and Payments in

General .

—

Fee-for-service

payments

may be made

separately for professional fees and hospital charges, or

both, based on arrangements with health care providers.

This fee shall be based on a schedule to be established by

the Board which shall be reviewed every three (3) years.

Fees paid for professional services rendered by salaried

public providers shall be allowed to 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 allowed to be retained by

the individual facility in which services were rendered and

for which payment was made. Such revenues shall be

used to 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.

SECTION 36. Role of Local Government Units (LGUs). —

Consistent

with

the

mandates

for

each

political

subdivision under Republic Act No. 7160 or ' The Local

Government Code of 1991 ', LGUs shall provide basic health

care services.

To augment their funds, LGUs shall invest the capitation

payments given to them by the Corporation on health

infrastructures or equipment, professional fees, drugs

and supplies, or information technology and database:

Provided, That basic health care services, as defined by

the DOH and the Corporation, shall be ensured especially

with the end in view of improving maternal, infant and

child

health:

Provided,

further ,

That

the

capitation

payments shall be segregated and placed into a special

trust fund created by LGUs and be accessed for the use of

such mandated purpose.

(National Health Insurance Act of 2013, Republic Act No.

10606, [June 19, 2013])

SECTION 37. Quality Assurance . — Under the guidelines

approved by the Corporation and in collaboration with

their respective Offices, health care providers shall take

part in programs of quality assurance, utilization review,

and

technology assessment that have the following

objectives:

a) to ensure that the quality of personal health services

delivered, measured in terms of inputs, process, and

outcomes, are of reasonable quality in the context of the

Philippines over time;

b) to ensure that the health care standards are uniform

within the Office's jurisdiction and eventually throughout

the nation; and

c) to see to it that the acquisition and use of scarce and

expensive

medical

technologies

and

equipment

are

consistent with actual needs and standards of medical

practice, and that:

1)

the

performance

of

medical

procedures and the

administration of drugs are appropriate, necessary and

unquestionably consistent with accepted standards of

medical practice and ethics. Drugs for which payments

will be made shall be those included in the Philippine

National Drug Formulary, unless explicit exception is

granted by the Corporation.

2)

the

performance of medical procedures and the

administration of drugs are appropriate, consistent with

accepted standards of medical practice and ethics, and

respectful of the local culture.

SECTION

38.

Safeguards

Against

Over

and

Under

Utilization . — It is incumbent upon the Corporation to set

up

a

monitoring

mechanism

to

be

operationalized

through a contract with health care providers to ensure

that there are safeguards against:

a) over-utilization of services;

b) unnecessary diagnostic and therapeutic procedures

and intervention;

c) irrational medication and prescriptions;

d) under-utilization of services; and

e) inappropriate referral practices.

The Corporation may deny or reduce the payment for

claims

when

such

claims

are

attended

by false or

incorrect

information

and

when

the

claimants

fails

without justifiable cause to comply with the pertinent

rules and regulations of this Act.

© Compiled By RGL

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