National Health Insurance Act of 2013

Section 30

Beneficiaries requiring treatment or confinement shall be free to choose from accredited health care providers. Such choice shall, however, be subject to limitations based on the area of jurisdiction of the concerned Office and on the appropriateness of treatment in the facility chosen or by the desired provider.

Section 31

The Corporation shall have the authority to grant to health care providers accreditation which confers the privilege of participating in the Program.

Section 32

All health care providers, as enumerated in Section 4(o) hereof and operating for at least three (3) years may apply for accreditation: Provided, That a health care provider which has not operated for at least three (3) years may likewise apply and qualify for accreditation if it complies with all the other accreditation requirements of and further meets any of the following conditions: (a) Its managing health care professional has had a working experience in another accredited health care institution for at least three (3) years; (b) It operates as a tertiary facility or its equivalent; (c) It operates in a LGU where the accredited health care provider cannot adequately or fully service its population; and (d) Other conditions as may be determined by the Corporation. A health care provider found guilty of any violation of this Act shall not be eligible to apply for the renewal of accreditation. (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

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

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

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 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

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

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

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.