Implementing Rules and Regulations of Program I of the Revised Philippine Medical Care Act as amended (P.D. No. 1519, as amended)

June 13, 1995

PHILHEALTH BOARD RESOLUTION NO. 1995-0005

WHEREAS, pursuant to Sections 5, 16, 49 and 50 of Republic Act No. 7875, otherwise known as an Act Instituting a National Health Insurance Program for all Filipinos and establishing the Philippine Health Insurance Corporation (PHIC) for the purpose, the PHIC is empowered, as follows: wEEieL

a. To formulate and promulgate policies for the sound administration of the program.

b. To set standards, rules and regulations necessary to ensure quality of care, appropriate utilization of services, fund viability, member satisfaction, and overall accomplishment of Program objectives.

c. To formulate the rules and regulations necessary for the implementation of RA 7875.

d. To follow the existing rules and regulations of the Philippine Medical Care Commission until such time that the Corporation shall have promulgated its own implementing rules and regulations.

e. To create the National Health Insurance Program initially consisting of Programs I and II of Medicare and be expanded progressively to constitute one Universal Health Insurance Program for the entire population.

WHEREFORE, the Board resolves as it is hereby resolved, that the Implementing Rules and Regulations of Program I of the Revised Philippine Medical Care Act, (Approved by the Philippine Medical Care Commission on August 27, 1987, during the 755th Regular Meeting under Medicare Resolution Number 87-1962 and confirmed on December 8, 1987 during the 758th Regular Meeting under Medicare Resolution Number 87-1987.), as amended, is hereby adopted to constitute as the initial and interim implementing rules and regulations of RA 7875. Provided, however, that any provision thereof, any other laws, Executive Orders, Administrative Rules and Regulations or parts thereof which are inconsistent with the provisions of RA 7875 are hereby declared repealed.

Approved this 13th day of June 1995, during the 03-95 Philippine Health Insurance Corporation (PHIC) Board meeting.

(SGD.) JAIME Z. GALVEZ TAN, MD, MPHChairpersonActing Secretary, Department of Health

(Ma. Celia P. Balugat signed)RAFAEL M. ALUNAN IIIMemberSecretary, Department of Interior and Local Government

(SGD.) JOSE BRILLANTESMemberActing Secretary, Department of Labor and Employment

(SGD.) LINA B. LAIGOMember

Acting Secretary, Department of Social Welfare and Development

(SGD.) CESAR N. SARINOMemberPresident & General Manager, Gov't. Service Insurance System

(SGD.) RENATO C. VALENCIAMemberAdministrator, Social Security System

IMPLEMENTING RULES AND REGULATIONS OF PROGRAM I OF THE REVISED PHILIPPINE MEDICAL CARE ACT

Pursuant to Section 6 of Presidential Decree No. 1519, as amended, otherwise known as the Revised Philippine Medical Care Act defining the functions, powers and duties of the Philippine Medical Care Commission, to wit: LEEuLd

(a) To formulate policies for, administer and implement the Medical Care Plan,

(b) To promulgate or prescribe rules and regulations necessary to carry out the provisions and purposes of the Revised Philippine Medical Care Act,

the implementing rules and regulations are hereby amended as follows:

RULE I

Definition of Terms

SECTION 1. For purposes of these rules, the following terms shall be understood as:

(a) ACCREDITED BED CAPACITY— Number of hospital beds authorized by the Commission to be used for Medicare purposes.

(b) ADMINISTRATIVE ORDERS — Written promulgations in the form of PMCC Resolutions, Medicare Circulars, Memorandum Circulars, Special Orders, and Office Orders issued and duly circularized by the Commission, pertaining but not limited to conducting, directing or superintending the execution, application or conduct and affairs of the Program as embodied in the Medicare Law, R.A. 6111 as amended by P.D. 1519 and its Implementing Rules and Regulations including Medicare accreditation warranties.

(c) BENEFICIARIES — The Medicare members and their legal dependents; death and total/permanent partial disability and old age pensioners of SSS and their dependents; GSIS retirees under RA 660, RA 1616 and their dependents. (As amended by PMCC Res. No. 90-2176). PmdPmm

(d) CIRCUMSTANCE — Any attendant situation present in a given case which tends to exempt or aggravate the violation and liability of the respondent.

(e) COMMISSION— The Philippine Medical Care Commission created under R.A. 6111, as revised.

(f) CONFINEMENT — Admission and stay in a hospital due to illness or bodily injury, medical and/or surgical, requiring hospitalization.

(g) DIAGNOSTIC/TREATMENT TERMINOLOGY— Terminology which conforms with the American Standard of Nomenclature of Diseases and Operations or the International Classification of Diseases.

(h) EMERGENCY— Means medical and surgical conditions that threaten immediate loss of life when not attended to.

(i) GSIS — The Government Service Insurance System created under Commonwealth Act 186, as amended.

(j) HOSPITAL — A health care facility with an organization of professional health workers and supportive personnel housed in a physical plant having adequate facilities and equipment to render medical care and ancillary health service on an out-patient and in-patient basis, duly licensed by the Department of Health, member in good standing of a national association of government and privately owned hospitals whose membership comprises the majority of licensed hospitals in the Philippines, and with a continuing program for hospital administration and discipline of its members, accredited and categorized by the Commission under such terms and conditions as it may set.

(k) LEGAL DEPENDENT — The legal dependents of a member are: 1) The legitimate spouse who is not a Medicare member; 2) the unmarried and unemployed legitimate, legitimated, acknowledged children as appearing in the birth certificate; legally adopted or stepchildren below 21 years of age; 3) children who are suffering from congenital disability either physical or mental, or any disability acquired below the age of 21 that renders them totally dependent upon the member for support; 4) the parents who are 60 years old and above whose income is P1,000.00 or less a month. Eiiwns

(l) MEDICARE SERVICE BEDS — Hospital beds set aside for beneficiaries as may be prescribed by the Commission, and when occupied by a Medicare beneficiary, no fees beyond Medicare rates shall be charged to the account of the beneficiary.

(m) MEDICINE — A drug, mixture of drugs, active principle, chemical product, preparation mixtures or combination of drugs intended for cure and/or prevention of complications or rehabilitation.

(n) MEMBER — Any person covered by SSS or GSIS either compulsorily or by special coverage.

(o) OPERATING ROOM COMPLEX— Means emergency room, delivery room, operating room, and recovery room.

(p) OTHERS — All items used in the management of the patient excluding medicine, consisting of but not limited to syringe, gloves, vaco sets, butterfly, including contrast media and other agents used in establishing the correct diagnosis and treatment of the patient. maimam

(q) PRACTITIONER — Any doctor of medicine or dental medicine duly licensed/authorized to practice in the Philippines, a member in good standing of a national association of government and privately-employed physicians or dentists whose membership comprises the majority of registered practicing physicians or dentists in the Philippines and with a program of continuing medical education and discipline for its members, and accredited by the Commission under such terms and conditions as it may set.

(r) PROVIDER — A practitioner, hospital, or other persons or facilities engaged in health care services and accredited by the Commission under such terms and conditions as it may set.

(s) RELATIVE UNIT VALUE — Points assigned to surgical procedures according to their comparative complexity as adopted by the Commission.

(t) SINGLE PERIOD OF CONFINEMENT — A single confinement or series of confinements for the same illness, with intervals of not more than ninety (90) days.

When a patient is admitted in the same or another hospital within five (5) days immediately following a previous discharge, such patient shall be deemed to be suffering from the same illness unless the chief complaints, clinical manifestations, and the course of management are entirely different from its first confinement.

(u) SSS — The Social Security System created under R.A. 1161, as amended. miaimn

(v) SYSTEM— The GSIS or SSS as the case may be.

(w) VIOLATION— Any act or omission constituting infraction of:

1) the provisions of P.D. 1519, as amended; and/or

2) the Medicare implementing rules and regulations; and/or

3) the warranties of accreditation; and/or

4) administrative orders of the Commission; and/or

5) other Medicare related laws, decrees, and regulations.

RULE II

Coverage

SECTION 1. The nature and scope of coverage under the Philippine Medical Care Act shall be compulsory on all persons covered by the SSS or GSIS including existing laws covering retirees from the government service and other special coverage. PaEeui

SECTION 2. Registration of Membership. — Registration and recording of members shall be according to the respective charters of the system.

SECTION 3. Dual Membership. — A person covered by both Systems may choose under which System he shall be covered for purposes of Medicare under such procedures as may be circularized by the Commission.

SECTION 4. Dual Coverage. — In cases where both members-parents are covered by Medicare, one under SSS and the other under GSIS, the members shall have the right to choose under whose membership their dependents shall be covered. This rule shall however apply only if there is disparity in benefits from both Systems. (As amended by PMCC Res. No. 93-2418)

RULE III

Benefits

The benefits under the Medicare Act consist of the following: hospital room and board; medical expense consisting of medicines, x-ray, laboratory examinations, and others; professional fees which include surgical, medical/dental, and anesthesiologist fees; operating room fees; and surgical family planning procedures (sterilization benefits).

SECTION 1. Entitlement to Benefits. — A beneficiary shall be entitled to benefits if he meets the following conditions:

(a) He is confined in a hospital due to illness or injury requiring hospitalization; or undergoes a surgical procedure in the operating room complex on an out-patient basis or receives chemotherapy, radiotherapy, or hemodialysis similarly on an out-patient basis.

(b) The member has paid at least three (3) monthly contributions through salary deduction within the immediate twelve (12) month period prior to the first day of confinement; provided that in the case of a self-employed member, he shall have qualified under the registration rules of the SSS and has paid the aforementioned monthly contributions prior to the first day of confinement.

(c) The 45-day room and board allowance for the calendar year has not been consumed. wIPwLd

SECTION 2. Types of Benefits. — A beneficiary of Program I who is confined in a hospital on account of sickness or injury requiring hospitalization is entitled to confinement days per calendar year as follows: a) Maximum of forty-five (45) days for all dependents. Any unused benefits for any prior year shall not be carried over to the succeeding year. The benefits for such confinement shall not exceed the following:

(a) The Medical Care Benefits of Medicare beneficiaries covered by the Social Security System (SSS) shall not exceed the rates indicated below:

			HOSPITAL CATEGORY
	BENEFIT		PRIMARY	SECONDARY	TERTIARY
1.	Room and Board not
	exceeding 45 days per
	year for each member
	of the Program I and
	another 45 days per
	year to be shared by
	all his legal dependents	P55.00/day	P100.00/day	P145.00/day
2.	Medical Expense (per
	Single Period of
	Confinement)
	2.1	Ordinary Cases
		2.1.1	Drugs & Medicines	P595.00	P790.00	P1,015.00
		2.1.2	X-ray/Laboratory/Others	150.00	360.00	635.00
	2.2	Intensive Care Case
		2.2.1	Drugs & Medicines	P1,350.00	P1,620.00	P2,915.00
		2.2.2	X-ray/Laboratory/Others	325.00	830.00	1,260.00
	2.3	Catastrophic Cases
		2.3.1	Drugs & Medicines		P3,650.00	P4,170.00
		2.3.2	X-ray/Laboratory/Others		1,620.00	3,845.00
3.	Medical/Dental
	Practitioner's Fee
	shall be P55.00 per
	day for a General
	Practitioner and
	P80.00 for a
	Specialist but not to
	exceed:
	3.1	For Ordinary
		Cases (per single
		period of confinement)
		For General Practitioner	P300.00	P300.00	P300.00
		For Specialist	450.00	450.00	450.00
	3.2	For Intensive
		Care/Catastrophic
		Cases (per single
		period of confinement
		For General Practitioner	P450.00	P450.00	P450.00
		For Specialist	750.00	750.00	750.00
4.	Surgeon's Fee shall be
	in accordance with the
	Relative value Scheme
	prescribed by the
	Commission not to
	exceed P7,080.00.
5.	Anesthesiologist's Fee
	(30% of allowed
	Surgeon's fee) not to
	exceed P1,410.00
6.	Operating Room fee for
	Surgical Procedures
	with Relative Unit
	Value of:
			0 – 5	P170.00	P295.00	P470.00
			5.1 – 10		505.00	600.00
			10.1 – Above		960.00	1,550.00
7.	Fees for Surgical
	Family Planning
	Procedures as may be
	determined by the
	Commission.
	Vasectomy		400.00	400.00	400.00
	Tubal Ligation		500.00	500.00	500.00

(b) The Medical Care Benefits of Medicare beneficiaries covered by Government Service Insurance System (GSIS) shall not exceed the rates indicated below: Errdme

				HOSPITAL CATEGORY
	BENEFIT		PRIMARY	SECONDARY	TERTIARY
1.	Room and Board not
	exceeding 45 days per
	year for each member
	of the Program I and
	another 45 days per
	year to be shared by
	all his legal dependents	P55.00/day	P100.00/day	P120.00/day
2.	Medical Expense (per
	Single Period of
	Confinement)
	2.1	For Ordinary Cases
		2.1.1	Drugs & Medicines	P595.00	P790.00	P845.00
		2.1.2	X-ray/Laboratory/Others	125.00	300.00	530.00
	2.2	For Intensive Care Cases
		2.2.1	Drugs & Medicines	P1,125.00	P1,350.00	P2,430.00
		2.2.2	X-ray/Laboratory/Others	270.00	690.00	1,050.00
	2.3	For Catastrophic Cases
		2.3.1	Drugs & Medicines	–	P3,040.00	P3,475.00
		2.3.2	X-ray/Laboratory/Others	–	1,350.00	3,205.00
3.	Medical/Dental
	Practitioner's Fee
	shall be P55.00 per
	day for a General
	Practitioner and
	P80.00 for a
	Specialist but not to
	exceed:
	3.1	For Ordinary
		Cases (per single
		period of confinement)
		For General Practitioner	P300.00	P300.00	P300.00
		For Specialist	450.00	450.00	450.00
	3.2	For Intensive
		Care/Catastrophic
		Cases (per single
		period of confinement)
		For General Practitioner	P450.00	P450.00	P450.00
		For Specialist	750.00	750.00	750.00
4.	Surgeon's Fee shall be
	in accordance with the
	Relative Value Scheme
	prescribed by the
	Commission not to
	exceed P7,080.00.
5.	Anesthesiologist's Fee
	(30% of allowed
	Surgeon's fee) not to
	exceed P1,410.00
6.	Operating Room fee for
	Surgical Procedures
	with Relative Unit
	Value of:
			0 – 5	P140.00	P245.00	P300.00
			5.1 – 10		420.00	500.00
			10.1 – Above		960.00	1,290.00
7.	Fees for Surgical
	Family Planning
	Procedures as may be
	determined by the
	Commission.
	Vasectomy		P400.00	P400.00	P400.00
	Tubal Ligation		500.00	500.00	500.00

 

(As amended by Executive Order Nos. 949, 1984; 1079, 1986; 106, 1986; 344, 1989; 365, 1989; 441, 1990; 501, 1991; and PMCC Res. No. 93-2379 as approved by the President in 1993) IwrLto

CATASTROPHIC CASES shall include the following:

1. Illnesses or injuries such as cancer cases requiring chemotherapy and/or radiotherapy, meningitis, encephalitis, cirrhosis of the liver, myocardial infarction, cerebro vascular attack, rheumatic heart disease — Grade III, renal conditions requiring dialysis or transplant, massive hemorrhage;

2. Surgical procedures or multiple surgical procedures done in one sitting with a total Relative Unit Value of 20 and above such as coronary bypass, open heart surgery, neurosurgery shall be considered catastrophic.

INTENSIVE CARE CASES shall include the following:

1. All confinements in an intensive care unit other than those classified as catastrophic;

2. Other similar serious illnesses or injuries such as cancer, pneumonia, moderately and far advanced pulmonary tuberculosis including its complications, cardiovascular attack, diseases of the heart, chronic obstructive pulmonary disease, liver disease, typhoid fever, H-fever, kidney disease, septicemia, diarrhea with severe dehydration, severe injuries, black water fever;

3. Surgical procedure or multiple surgical procedures done in one sitting with a total Relative Unit Value of 8 and above but not exceeding 19.99 shall be considered as intensive care cases.

ORDINARY CASES are illnesses or injuries other than those included in the above enumeration. rnmuwo

For purposes of reimbursement of medicines, a mark-up of not more than 50% of the price based on the latest and updated issue of Philippine Index of Medical Specialties (PIMS) shall be adopted.

Further, no take home medicines are allowed for Medicare patients except those left-over in bottled liquid form. (As amended by PMCC Res. No. 94-2497)

(c) ALLOWANCE FOR PROFESSIONAL FEES

1) The Surgeon's fee shall include two (2) days of pre- and five (5) days of post-operative care.

Surgical procedures without any assigned Relative Unit Value shall be evaluated taking into consideration its similarity to existing procedures.

Two or more surgical procedures done through the same incision shall be considered as a single procedure and shall be paid based on the highest Relative Unit Value.

Specialists who rendered services outside of their specialties shall be paid the General Practitioner professional fee. (As amended by PMCC Res. No. 91-2295)

A qualified beneficiary who undergoes surgical procedure in the hospital operating room complex on an out-patient basis is entitled to benefits provided that one day is deducted from his forty-five (45) day room and board benefits.

All claims for surgical expense shall be made by listing the operation as appearing in the Standard Nomenclature of International Classification of Surgical Procedures.

2) To be entitled to the above Anesthesiologist's fee, the following must be observed:

(a) Only one anesthesiologist shall be compensated for each operation;

(b) Local anesthesia is not compensable except when it is a regional nerve block anesthesia;

(c) When the operating surgeon administers anesthesia himself, no separate anesthesiologist's fee shall be allowed.

SECTION 3. Exclusions. — The above benefits shall not include expenses for the following: ImPmui

(a) Cosmetic surgery or treatment — surgery or treatment to preserve, enhance or restore comeliness, the primary purpose of which is to beautify or bring about aesthetic effects;

(b) Optometric services;

(c) Psychiatric illness;

(d) Services which are purely diagnostic in nature such as routing physical and medical examinations, executive check-ups, and similar medical diagnostic services;

(e) Normal obstetrical delivery — any vaginal delivery which is not complicated by eclampsia, retained placenta, profuse bleeding requiring surgical intervention, breech extraction or similar complications; Provided that, any repair of Episiotomy in first vaginal delivery is compensable under the Medicare Program. (As amended by PMCC Res. No. 93-2403)

(f) Circumcision — circumcision per se is not compensable but circumcision with complication is compensable regardless of age. (As amended by PMCC Res. No. 91-2264)

SECTION 4. Requirements for Availment of MEDICARE Benefits: (As amended by PMCC Res. No. 90-2176) —

(a) Members:

1) A member must present to the hospital a duly accomplished PMCC Form I.

2) A self-employed member must present a true copy of his registration and receipt of payment (SSS Form, RS-5). unPeoi

3) A retiree from the public sector must present a certificate or other evidence to prove that he is a qualified retiree from the public service such as annuity voucher or xerox copy of approved retirement application.

4) A death (survivorship) and total/permanent partial disability and old age pensioners of SSS must present the following documents aside from PMCC Form I:

4.1 his latest pension voucher;

4.2 xerox copy of the cover of his Mag-impok Passbook;

4.3 certificate from Pensions Department or Regional Office of SSS.

5) A retiree under RA 660, RA 1616 (Retirees under RA 1616 should be 60 years of age at the time of hospitalization) and PD 1146, must present any of the following documents aside from PMCC Form I:

5.1 xerox copy of retirement voucher;

5.2 certification from GSIS.

(b) Dependents:

1) Dependent parents/spouses/children — submission of a duly accomplished PMCC Form I shall be prima facie evidence of dependency status. Verification of the status of the dependent by the System shall not suspend the usual processing of the claim and payment to the hospital and medical or dental practitioner without prejudice to whatever recourse the System may take against the member. Whenever there is a need, it shall be the obligation of the member to furnish the corresponding System through his employer with an updated list of his legal dependents as defined herein. In the case of a newly born dependent, a certified xerox copy of the birth certificate shall be submitted. tnPEEn

2) Dependents of SSS Pensioners — any of the following documents shall be submitted to the hospital in addition to the PMCC Form I:

2.1 E-1 or E-4 duly stamped received by the SSS or Marriage Contract for dependent-spouse;

2.2 E-1 or E-4 duly stamped received by the SSS or birth certificate for dependent-children;

2.3 E-1 or E-1 duly stamped received by the SSS or affidavit of support for dependent-parents.

3) Dependents of GSIS Retirees — any of the following documents shall be submitted to the hospital in addition to the PMCC Form I:

3.1 xerox copy of Marriage Contract for dependent-spouse;

3.2 birth certificate for dependent-children;

3.3 affidavit of support for dependent-parent.

SECTION 5. Benefits of Members While Abroad. —

(a) A member, including his legal dependents, who is abroad shall be eligible to Medicare benefits while outside the country provided the conditions for entitlement in Section 1(b) and (c) of this Rule are met.

(b) The medical care benefits to be granted shall be paid in equivalent the provisions of Section 12 of P.D. 1519, local rate based on tertiary category of hospital. (As amended by PMCC Res. No. 94-2476) euounI

SECTION 6. Benefits of Patients Confined in Service Beds. — The cost of medical care services of patients confined in Medicare service beds shall be limited to the prescribed medical care benefit allowances.

RULE IV

Payment of Claims

SECTION 1. General Provisions. —

(a) A member shall be free to choose from among the accredited hospitals and physicians. However, when he has no choice of physicians, he shall be considered under the care of the medical staff of the hospital.

(b) The hospital and the attending physician shall file their claims through the prescribed PMCC forms. All Medicare accredited hospitals shall attach PMCC Form 2 to the clinical records of a Medicare patient upon admission. Further, it shall be the responsibility of the nursing staff in the ward to see to it that PMCC Form 2 is signed by the attending physician on or before the order of discharge of the patient. (As amended by PMCC Res. No. 91-2293)

(c) All claims for payment of services rendered shall be filed within sixty (60) calendar days from the day of discharge of the patient or from the time that he has been declared well, otherwise the claim shall be barred except in case of force majeure. If the claim is sent through the mail, the date of mailing as stamped by the Post Office of origin shall be considered as the date of filing.

A claim returned by the System for completion of supporting documents must be refiled within 120 days from its receipt by the hospital.

The cut-off period for filing of appeals for denied/reduced and/or unpaid Medicare claims is six months from receipt of notice of denial/reduction from the Systems. (As amended by PMCC Res. No. 95-2694)

(d) When the beneficiary has complied with the requisites for availment as Medicare patient under Section 4 of Rule III, the hospital and the practitioner shall deduct from the hospitalization costs all expenses reimbursable by Medicare. Payment of medical benefits shall be made directly to the hospital, the medical or dental practitioner and the retail drugstore only. No direct payment to patients is allowed except in the case of Medicare compensable confinements abroad of members and their dependents. (As amended by PMCC Res. No. 93-2371) emeEsm

(e) If the hospital has already deducted the Medicare share from the hospital bill and the System should reimburse the Medicare claims of the hospital, the System is authorized to take measures to recover against the member. If the cause of the delay is within the control of the Providers, the hospital should shoulder the Medicare share chargeable to the future claims of the hospital. (As amended by PMCC Res. No. 93-2371)

(f) The System may deny or reduce any benefit provided by the Philippine Medical Care Plan when the beneficiary:

1. Fails without good cause or legal ground to comply with the advice of the medical practitioner with respect to the hospitalization; or

2. Furnishes false or incorrect information concerning any matter required by law or the Rules and Regulations on Medicare.

In such cases, the member may be required to pay for the amount denied or reduced except when false information was supplied by the employer, in which case, the System shall intervene in behalf of the member or the hospital against the employer.

The System may deny or reduce any benefit provided by the Philippine Medical Care Plan when the health provider:

1. Furnishes false or incorrect information concerning any matter required by law or the Rules and Regulations of Medicare; or

2. Fails to comply with any provision of the Rules and Regulations governing the Medicare Program.

When the claim is reduced or denied, the amount thus reduced or denied shall not be charged directly or indirectly to the beneficiary involved unless the latter is directly responsible for the cause of such reduction or denial. Any and all actions taken by the System on the claims may be appealed to the Commission whose decision shall be final.

(g) Primary hospitals are required to submit clinical records of patients in connection with their Medicare claims.

(h) Family-owned secondary and tertiary hospitals which have violated rules and regulations may be required, upon recommendation of the Hearing Committee, to submit the same until such time that the Commission lifts such requirements. PtinPi

(i) All employee hospitalization claims not compensable under the Employees Compensation Program shall be automatically considered as a claim under the Medicare Program provided that the claim has been filed within the reglementary period of sixty (60) days.

(j) When the bed census as reflected by claims filed with the System exceeds its accredited bed capacity, such claims shall be accompanied by justification in writing, otherwise these shall not be given due course.

(k) Any operation performed beyond the authorized capability of the hospital shall be considered a violation, except when done in emergency to save life or referral to a higher category hospital is physically impossible. Primary care hospital shall be compensated only for simple operations as listed by the Commission.

(l) Confinement in a non-Medicare accredited hospital in emergency case will be paid, provided referral to a Medicare accredited hospital is physically impossible. In case the confinement is non-emergency and the hospital is not accredited, the patient is entitled to professional fee if services are rendered by a Medicare accredited physician. Payment of emergency confinement in non-accredited hospitals shall be based on the category of hospitals as licensed by the DOH. Accredited physicians who rendered services in a non-accredited hospital shall be paid, even if the confinement is non-emergency and the hospital is not accredited. (As amended by PMCC Res. Nos. 91-2282, 91-2288, 92-2319 and 94-2476)

RULE V

Collection/Remittance of Contributions

SECTION 1. Rates of Contributions. — a) The contribution of members shall be in accordance with billing procedures of the SSS and GSIS as the case may be. (As amended by Sec. 9, Exec. Order No. 269, 1987 & Exec. Order No. 365, 1989) tIowIE

For GSIS members, the contribution shall be computed at 2.5% to be shared equally by employers and employees, of the basic monthly salary subject to sub-section (b) hereof.

For SSS members, monthly contribution shall be in accordance with the following schedule subject to sub-section (b) hereof.

SALARY BRACKET	CONTRIBUTION	EMPLOYEE'S	EMPLOYER'S
	BASE	SHARE	SHARE
less than P149.99	P125.00	P1.55	P1.55
150.00 – 199.99	175.00	2.20	2.20
200.00 – 249.99	225.00	2.80	2.80
250.00 – 349.99	300.00	3.75	3.75
350.00 – 499.99	425.00	5.35	5.35
500.00 – 699.99	600.00	7.50	7.50
700.00 – 899.99	800.00	10.00	10.00
900.00 – 1,099.99	1,000.00	12.50	12.50
1,100.00 – 1,399.99	1,250.00	15.65	15.65
1,400.00 – 1,799.99	1,500.00	18.75	18.75
1,750.00 – 2,249.99	2,000.00	25.00	25.00
2,250.00 – 2,749.99	2,500.00	31.25	31.25
2,750.00 – over	3,000.00	37.50	37.50

b) The maximum contribution base for all members shall continue to be limited to P1,000.00 per month until December, 1990; however, maximum contribution base shall be increased to P2,000.00 starting January 1, 1992 and to P3,000.00 starting January 1, 1993. mwrioi

SECTION 2. Collection of Contributions. —

(a) The members contribution shall be deducted and withheld by the employer from the former's salary, wage or earnings. Failure of the employer to deduct the same shall not be a basis for invalidation of a properly filed claim.

(b) The employer's counterpart contribution shall not in any manner be recovered from the employee.

SECTION 3. Remittance of Contribution. — The monthly contribution of members shall be remitted by the employer directly to the System, as the case may be, in accordance with the respective rules and regulations. Remittance shall be accompanied by the appropriate forms.

 

Failure of the employer to remit to the System the corresponding employee's and employer's contribution shall not be a reason for depriving the beneficiary of his benefits under the law. mwrioi

RULE VI

Effect of Separation, Re-Employment or Transfer

SECTION 1. Separation from Employment. —

(a) When a covered employee is separated from employment, his employer's obligation to remit the applicable Medicare contributions on his behalf ceases from the date of separation. The separated employee may elect to continue his Medicare membership by giving a written notice to the System and paying the same monthly Medicare contribution representing the employer's and his own.

(b) The option to continue membership shall be approved when exercised within six (6) months following the date of separation. If he fails to pay the corresponding contributions after the option to continue has been exercised, the membership is terminated.

SECTION 2. Effect of Re-Employment. — Should the separated employee be re-employed, his new employer shall assume the obligation of reporting and remitting the monthly contribution based on the employee's covered wage under his new employment.

SECTION 3. Transfer of Membership. — When an employee transfers from private to government employment, his medical care coverage under the SSS shall cease when he becomes covered under the GSIS. When the transfer is from government to private employment, medical care coverage under the GSIS shall cease when the employee is covered under SSS. Provided, the rights of the beneficiary under Section 15 of the Medical Care Law shall not be prejudiced. The obligation to remit contributions shall be on the basis of his employment. The employee and the employer shall jointly notify the System of such transfer of employment. LonPue

RULE VII

Accreditation

SECTION 1. Prerequisites. — A hospital may be accredited if it satisfies the following prerequisites:

(a) It must be licensed by the Department of Health; and

(b) It must be a member in good standing of a national association of government and privately-owned hospitals whose membership comprises the majority of licensed hospitals in the Philippines and with a continuing program for hospital administration and discipline of its members. (As amended by PMCC Res. No. 89-2132)

SECTION 2. Prerequisites. — A practitioner may be accredited if he satisfies the following prerequisites:

(a) He must be licensed to practice in the Philippines; and

(b) He must be a member in good standing of a national association of government and privately-employed physicians or dentists whose membership comprises the majority of licensed physicians/dentists in the Philippines and with a program of continuing medical education and discipline of its members.

SECTION 3. Terms and Conditions. —

(a) The hospital must comply at all times during the period of accreditation with all the requisites of R.A. 4226 otherwise known as the Hospital Licensure Act and its Implementing Rules and Regulations, and other DOH Administrative Orders;

(b) The practitioner must comply at all times with the Code of Ethics as prescribed under Section 24, Paragraph 12 of the Medical Act of 1959, as amended;

(c) The hospital and practitioner must comply at all times during the period of accreditation with all the requirements of the Medicare Law, including its Implementing Rules and Regulations, warranties of accreditation, and other administrative orders of the Commission;

(d) Hospitals and Medicare providers agree to have their pending claims with the System be applied in satisfaction of the fine imposed, if any, as provided under Rule X, Section 15(d); and asEiri

(e) Hospitals affected by earthquake, fire, flood, volcanic eruption and any other conditions that will reduce its capability from rendering the services for which it was accredited should be reported immediately to the PMCC by the DOH and the PHA for a possible change of accreditation. (As amended by PMCC Res. No. 93-2369)

SECTION 4. Period of Accreditation. — The period of accreditation shall be for one (1) year for hospitals and three (3) years for practitioners to take effect upon the approval by the Commission; Provided that, initial accreditation shall take effect thirty days (30) after the hospital had fully complied with the requirements of accreditation. (As amended by PMCC Res. Nos. 93-2421 and 94-2471)

When a hospital changes ownership/management, accreditation terminates upon submission of either of the following:

(a) Deed of absolute sale;

(b) Letter informing the PMCC about transfer of ownership;

(c) Document showing mutual agreement of both parties regarding the sale of the hospital. (As amended by PMCC Res. No. 93-2357)

SECTION 5. Accreditation Fees. — For purposes of documentation and processing of applications for accreditation of Medicare providers, the Commission shall impose accreditation fees as may circularized from time to time.

SECTION 6. Commission Option. — The Commission has the option to accredit a number of beds less than the authorized bed capacity per DOH license.

SECTION 7. Denial of Accreditation. — The Commission may deny accreditation where there is a saturation of accredited hospitals based on the national hospital bed to population ratio or other standard as determined by the DOH or the renewal of such accreditation where there is a prima facie evidence of violation of the law and these rules and regulations. emEmai

In cases of two or more hospitals owned by the same person(s) and registered as a single proprietorship or partnership, the violation committed by the hospital owner/administrator/staff in one hospital shall be considered a strong ground for denial of accreditation for any hospital within the chain of hospitals the owner operates. (As amended by PMCC Res. No. 93-2355)

Any hospital found by the Commission to have violated Medicare laws and regulations and whose case is under appeal to the Office of the President but without any resolution from the latter shall be denied accreditation when their accreditation expires. (As amended by PMCC Res. No. 93-2356)

SECTION 8. Renewal of Accreditation. — Accreditation of hospitals without track records must be approved by the Accreditation Committee duly noted by the Board. Other hospitals with docketed cases and track records will have to be approved by the Board on a case to case basis. (As amended by PMCC Res. No. 94-2429) aoPLtL

RULE VIII

Payment of MEDICARE Benefits of Members Abroad

SECTION 1. Requirements. — The requirements shall include the following documents (in addition to the pertinent requirements for settlement of claims):

(a) Statement of account or the official receipt of payment from the foreign hospital where the patient was confined; and

(b) Certification of the attending physician as to the final diagnosis, period of confinement, and services rendered.

SECTION 2. Manner of Payment. — Payment shall be made to the beneficiary in equivalent Philippine currency based on tertiary category of hospital. (As amended by PMCC Res. No. 94-2476)

RULE IX

Supervision and/or Inspection

SECTION 1. The Commission and/or the System may exercise supervision through authorized representatives to perform such function. uEmaoe

SECTION 2. For purposes of inspection, all providers are required to give access to the medical records of Medicare patients to duly authorized representatives of the Commission and/or the System. Such representatives are likewise authorized to inspect the physical plant and equipment thereof.

SECTION 3. Whenever necessary and with the consent of the patient or the attending physician or director of the hospital, the Commission and the System representatives may conduct examinations on Medicare patients during confinement to determine whether laboratory procedures were actually performed or medications and/or treatment were actually administered.

RULE X

Hearing Procedures

In accordance with Section 29 of Presidential Decree No. 1519, as amended, the rules for hearing and/or investigation of cases or violation of Medicare Law and its Implementing Rules and Regulations shall be as follows: PuLtiu

SECTION 1. Grounds for Investigation. — Investigation shall be conducted by the Hearing Committee upon proper complaint for any violation of the following:

(a) the provision of P.D. 1519 as amended;

(b) its Implementing Rules and Regulations;

(c) the warranties of accreditation;

(d) administrative orders of the Commission;

(f) other subsequent Medicare related laws and regulations.

SECTION 2. Complaint. — The System, the Commission, any person, firm or corporation may file a complaint against any person, Medicare provider, and other juridical entities provided that complaints other than those filed by the System and the Commission shall be under oath. mIwmtm

The complaint shall state the name, residence, and such other personal circumstances of the complainant and those of the respondent, the substance of the facts and acts constituting the violation charged, the grounds of action and the relief sought. The complaint shall contain evidence in support of the complaint.

A complaint may be withdrawn by the complainant in writing which should also be verified. The Commission shall forthwith dismiss the complaint unless the Commission, for reasons of public interest, shall deem it necessary to prosecute, notwithstanding its withdrawal by the complainant.

SECTION 3. Summons. — The Hearing Committee, upon receipt of the complaint filed by the proper office or person, shall issue summons either by personal service or by registered mail to the respondent at his last known address or to his/her/its duly authorized representative or to any person having charge thereof attaching thereto copies of the complaints and other documents necessary to inform the respondent of the charges against her/him/it. eEwoet

SECTION 4. Answer. — Within fifteen (15) days from receipt of the summons, the respondent shall file his/her/its answer in writing and under oath, submitting six (6) copies thereof. The answer shall contain either an admission or specific denial of the material allegations in the complaint, or explanation why no action shall be taken against him/her/it. Failure to specifically deny the allegations shall be deemed an admission.

Failure of the respondent to answer as prescribed shall be a waiver of respondent's rights to present evidence on his/her/its behalf and the Hearing Committee shall proceed to deliberate on the case.

SECTION 5. Deliberation of the Hearing Committee. — After the answer has been received by the Hearing Committee or after the 15-day period within which the respondent should file his/her/its answer has lapsed, the case shall be scheduled for deliberation. The Hearing Committee, for the purpose of this Rule, may sit en banc or in division. It shall sit en banc in cases of motions for reconsideration and petitions for reconsideration of Preventive Suspension. muLEna

SECTION 6. Order of Referral and Fact-Finding Investigation. —

(a) The order of referral shall contain the specifications or guidelines as to what problem areas or issues the Committee wants to be clarified, informed, or enlightened.

(b) Within twenty-one (21) working days from receipt of the order of referral from the Hearing Committee, the investigating body or officer shall conduct investigation in accordance with the following:

1. In case the Hearing Officer or a member of the investigating body shall be involved directly/indirectly in the complaint under investigation, he/she shall abstain or inhibit himself/herself from the investigation. The respondent shall be afforded ample opportunity to be heard in person and/or thru counsel during the investigation.

2. The minutes of the investigation shall be duly recorded, transcribed, and attested to by the Hearing Officer or members of the investigating body, as the case may be.

(c) Within thirty (30) days after the termination of the investigation, the investigating body or Hearing Officer shall forward its/his findings and recommendations to the Hearing Committee, attaching thereto all the transcribed stenographic notes, if any, and such documents and other papers presented at the investigation pertinent to the case. In case the investigation is not terminated within the 21-day period, the investigating body or Hearing Officer shall submit to the Hearing Committee an explanation or information in writing about the delay. ssndiw

Upon receipt of the findings and recommendations of the body, the Hearing Committee shall convene within thirty (30) days to resolve the case with the report as its basis or to conduct further hearings when deemed necessary.

SECTION 7. Hearing. — In case the Hearing Committee in its deliberation deems it necessary to conduct further hearing/investigation, the parties shall be notified in writing of the scheduled date thereof.

A subpoena or subpoena duces tecum or both may be issued by the Chairman of the Committee or his duly authorized representative to compel attendance of witnesses or the production of books, papers, and other records deemed necessary in connection with any question pending before the Hearing Committee.

The filing of a criminal case involving the same facts in the administrative case shall not suspend proceedings in the latter case.

SECTION 8. Contempt. —

(a) Direct Contempt. A person guilty of misbehavior in the presence of or so near the Chairman or any member of the Commission, or of the Chairman or any member of the Hearing Committee as to obstruct or interrupt the proceedings before the same, including disrespect toward said officials, offensive personalities towards others, or refusal to be sworn or to answer as a witness or to subscribe an affidavit or deposition when lawfully required to do so may be summarily adjudged in Direct Contempt by said officials and punished by a fine not exceeding One Hundred Pesos (P100.00) or imprisonment not exceeding two (2) days or both if it be in the presence of the Chairman of the Commission or a member thereof, or by a fine not exceeding Fifty Pesos (P50.00) or imprisonment not exceeding one (1) day or both if it be in the presence of the Chairman of the Hearing Committee or a member thereof. Judgment of Direct Contempt is immediately executory and unappealable in court. dtatts

(b) Indirect Contempt shall be dealt with by the Commission or Hearing Committee in the manner prescribed under Rule 71 of the Revised Rules of Court.

SECTION 9. Ex-parte Proceedings. — In case of failure of either party to appear at the time of hearing despite due notice, the Hearing Committee shall proceed to receive evidence ex-parte and decide on the basis of evidence adduced.

SECTION 10. Order of Hearing. —

(a) The lawyer of the Commission in charge of the case shall inform the members of the Hearing Committee of the nature of the complaint and/or status of the case every hearing thereafter.

(b) The complainant shall then proceed with the presentation of its evidence, oral or documentary. The complainant, his/her/its witness shall be subject to clarificatory questions by the respondent or by the members of the Hearing Committee. srmPra

(c) After the complainant has presented all his/her/its evidences, the respondent shall then proceed to present his/her/its evidences, oral or documentary, to support his/her/its answer. The respondent, his/her/its witnesses shall be subject to clarificatory questions by the complainant or by the members of the Hearing Committee. Presentation of rebuttal and/or surrebuttal evidence may be allowed upon motion by the proper party.

SECTION 11. Hearing Committee Resolution. — After the deliberation or hearing, the Hearing Committee shall immediately submit its findings and recommendations in the form of resolution to the Commission signed by all members who participated therein and shall contain clearly and distinctly the findings of facts and of the law which were the basis of the recommendation.

SECTION 12. Motion for Reconsideration. — A party not satisfied with the decision of the Commission may file a motion for reconsideration with the Commission in at least six (6) copies within the period for perfecting an appeal provided for in Section 13 hereof.

The motion for reconsideration shall clearly point out the following grounds:

(a) Error of law and/or fact relied upon by the party;

(b) Newly discovered evidence or fact which could not with reasonable diligence be discovered and produced at the hearing and when presented would probably alter the result of the investigation; and

(c) Fraud, accident, mistake, or excusable negligence which ordinary prudence could not have guarded against and by reason of which the right of the aggrieved party may have been impaired, which if true and correct shall validly justify a consideration of the decision.

otherwise, the same shall be deemed a pro-forma motion, hence, will not be given due course and therefore will not stay the running of the period after which the decision becomes final and executory in accordance with Section 13 hereof. Only one motion for reconsideration shall be entertained by the Commission. imdeeP

SECTION 13. Finality of Decision. — The decision of the Commission on the case shall become final and executory after the lapse of thirty (30) days from receipt of the decision by the parties. Within and before the lapse of the said period of appeal, the party concerned may file a Motion for Reconsideration or Appeal which shall stay the running of the thirty (30)-day prescriptive period.

SECTION 14. Appeal. — The party who is not satisfied with the decision of the Commission may appeal the same to the Commission within thirty (30) days from his receipt of the decision in accordance with the procedure established under Administrative Order No. 18 dated February 12, 1987.

SECTION 15. Execution/Enforcement of Decision. —

(a) Upon decision/resolution or order of the Commission that finally disposes of the case or proceeding for violation of the Medicare law, a writ of execution shall be issued upon the expiration of the period to file a Motion for Reconsideration/Appeal therefrom if no Motion for Reconsideration/Appeal has been perfected. If a Motion for Reconsideration has been filed, and a decision has been promulgated, a writ of execution shall be issued upon the expiration of the period to file an appeal. In appealed cases, upon the receipt of the records of the case by the Hearing Committee, notice shall be given to both parties informing them of the receipt of said decision. After notice, a writ shall be issued for the execution of the decision. (As amended by PMCC Res. No. 89-2078)

(b) The penalty of suspension or revocation shall be enforced by the temporary or permanent cessation, as the case may be, of the privilege and benefits under the Medicare Program. In which case, both Systems shall be duly advised in writing of the same. ndiiew

Where the respondent is meted the sanction of fine, the Commission shall issue a writ of execution enforceable in accordance with the Rules of Court.

(c) Except when the respondent voluntarily pays the fine within fifteen (15) days before the finality of the decision, the Committee may motu proprio issue a writ of execution for the purpose.

(d) Where a respondent has a pending claim for payment from the Health Insurance Fund (HIF), the fine imposed on such respondent may be enforced against the proceeds of such claim.

The System, upon receipt of the decision of suspension or revocation of accreditation and fine, shall immediately given notice as to the existence of such claim of the respondent. Upon order from the Commission, the System shall remit to the Commission so much amount charged against the claim in satisfaction of the fine.

SECTION 16. Applicability of the Provision of the Rules of Court. — Provisions of the Rules of Court which are consistent herewith may serve to supplement the provisions herein provided.

RULE XI

Preventive Suspension

SECTION 1. At any time after proper complaint has been filed in accordance with Rule X and pending the hearing and/or investigation of the case, the Hearing Committee hearing the case may preventively suspend any respondent beneficiary or provider from participation in the Medicare Program if any of the following circumstances is present: ersIow

(a) When the respondent has been found guilty of a violation of Presidential Decree No. 1519, as amended, or of its rules and regulations at least twice and there is reasonable ground to believe based on evidence that the respondent is guilty of the present charge;

(b) When the respondent, at the time of an authorized inspection thereof, has committed or is committing a violation.

SECTION 2. The preventive suspension order should contain or incorporate, by reference, documents containing a recital of the antecedent facts and circumstances mentioned in the preceding section, serving as basis for its issuance. The order shall likewise:

(a) specify the violation charged, citing also the particular evidence gathered or available in support of the violation;

(b) require the respondent to answer the charge within a period of ten (10) days from the date the respondent receives the order;

(c) require the respondent to appear on the date set for the hearing of the case; and

(d) state the period of the suspension, which period shall not exceed three (3) months from the date of its issuance. twtmua

SECTION 3. The order, being interlocutory in nature, shall be unappealable but a petition for reconsideration thereof may be filed with the Commission through the Hearing Committee. The mere filing of such petition shall not stay the preventive suspension order issued but the resolution of any petition for reconsideration shall not be delayed unnecessarily.

SECTION 4. When the hearing/deliberation and/or investigation of the case is not terminated within the period of suspension stated in the order, the preventive suspension order issued shall be automatically lifted after the expiration of such period stated in the order, except when the cause of non-termination is attributable to the respondent.

SECTION 5. The actual period of preventive suspension undergone or served by the respondent shall be credited in the service of the penalty of suspension that may be finally imposed upon the respondent in the decision of the case, in accordance with Section 15 of Rule X. weiost

RULE XII

Penalties

In the promulgation of decision, order or ruling of penalty for violations of Medicare Law, Rules and Regulations, Warranties of Accreditation, Administrative Order, the Hearing Committee shall be guided as follows:

PART I

General Provisions

SECTION 1. Serious, Less Serious and Light Violations. —

(a) Light violations are those which carry a penalty of fine of P5,000 and suspension from participation in the Medicare Program for not less than one month but not to exceed six months.

(b) Less Serious Violations shall carry a penalty of fine of more than P5,000 but not exceeding P15,000 and suspension for a period of not less than six months but not more than 11 months.

(c) Serious Violations shall carry a penalty of fine of more than P15,000 but not exceeding P30,000 and suspension of not less than 12 months or revocation. In case of revocation, a recommendation will be submitted to the Department of Health for cancellation of license to operate. aLnsoi

SECTION 2. Circumstances. —

The following circumstances shall affect the gravity of the violation and the liability of the respondent hospital or practitioner or beneficiary in the commission of violation(s).

(a) Mitigating Circumstances

The voluntary admission of guilt before the Hearing Committee prior to the conduct of preliminary investigation shall mitigate the liability of any hospital, practitioner or beneficiary for the violation committed.

There is a voluntary admission if during the initial investigation of the case or any time prior to the filing of complaint, the party admits the commission of the offense.

(b) Aggravating Circumstances

The following are aggravating circumstances which shall increase the liability from minimum to maximum:

1. Previous commission of less serious and/or serious violation.

2. Connivance with any employee of the Commission or the Systems to facilitate the commission of the violations.

3. Membership in the Commission or in any of its Committees when such membership is used to facilitate or cover-up the commission of violations.

4. Connivance with members. iimmso

SECTION 3. Scale of Penalties. — The scale or graduation of penalty shall be as follows:

(a) For Light Violations:

Maximum Penalty — (1) Accredited Hospitals or Practitioners — a fine of P5,000 and suspension of six months; (2) Beneficiaries — a fine of P5,000 and suspension of six months.

Medium Penalty — (1) Accredited Hospitals or Practitioners — a fine of P5,000 and suspension of four months; (2) Beneficiaries — a fine of P5,000 and suspension of three months.

Minimum Penalty — (1) Accredited Hospitals or Practitioners — a fine of P5,000 and suspension of two months; (2) Beneficiaries — a fine of P5,000 and suspension of one month.

(b) For Less Serious Violations:

Maximum Penalty — a fine of P15,000 and suspension for 11 months.

Medium Penalty — a fine of P10,000 and suspension for eight months.

Minimum Penalty— a fine of P5,000 and suspension for six months.

(c) For Serious Violations IdsaPs

Maximum Penalty — a fine of P30,000 and revocation of accreditation. A recommendation shall be submitted to the DOH for cancellation of license to operate.

Medium Penalty — a fine of P23,000 and suspension of accreditation for 18 months.

Minimum Penalty — a fine of P15,000 and suspension of accreditation for 12 months.

(d) Common Provisions — All penalties shall carry with them denial of payment of claim(s) in question and/or refund to the System if already paid.

Suspension shall be carried out by the temporary cessation of the benefits or privilege under the Medicare Program.

Should the aggregate period of suspension to be imposed upon the provider on account of two or more violations exceed 24 months, the maximum penalty for serious violations shall be imposed. In no case shall the penalty of fine exceed P30,000.

A notice of suspension for the information of beneficiaries shall be posted in the hospital indicating the period of suspension in such form and manner to be prescribed by the Commission.

A notice of suspension of benefits of a member shall be provided to all hospitals in the area. IImwmw

SECTION 4. Rules for Application of Circumstance in the Imposition of Penalties. —

(a) The presence of mitigating circumstance without any aggravating circumstance shall limit the imposable penalty to its minimum.

(b) When there are neither mitigating nor aggravating circumstances, the imposable penalty shall be between the minimum and maximum of the applicable penalty for violation committed at the discretion of the PMCC, the same shall apply when both mitigating and aggravating circumstances are present.

(c) The presence of any aggravating circumstance without the mitigating circumstance shall increase the penalty of the violation to its maximum.

PART II

Violations and Penalties

A. SERIOUS VIOLATIONS

SECTION 5. Violations and Penalties. —

			PENALTIES
		MINIMUM	MEDIUM	MAXIMUM
1.	Misrepresentation by	P15,000 and	P23,000	P30,000 and
	Padding of claims	suspension of	and suspension	revocation of
			accreditation	of accreditation	accreditation.
	Any provider, who	for 12 months.	for 18 months.	A recommendation
	for the purpose of			shall be
	claiming payment from			submitted to
	the Systems, files a			the DOH for
	Medicare claim for an			cancellation
	amount more than the			of license to
	benefits actually			operate.
	used by adding drugs,
	medicines, procedures,
	services, supplies not
	actually done or given.
2.	Misrepresentation by	P15,000 and	P23,000 and	P30,000 and
	Claiming for	suspension of	suspension of	revocation of
	non-Admitted Patients	accreditation	accreditation	accreditation.
			for 12 months.	for 18 months.	A recommendation
	Any provider,			shall be submitted to
	who for the purpose			the DOH for
	of claiming payment			cancellation
	for non-compensable			of license to
	out-patient illness			operate.
	from the Systems
	files a Medicare
	claim for
	non-admitted
	patients:
	a)	By making it
		appear that the
		patient is
		actually confined
		in the hospital
		when he is not; or
	b)	By making it
		appear that the
		non-compensable
		illness or
		procedure is
		compensable; and
	c)	By such other
		machinations.
3.	Misrepresentation by	- do -	- do -	- do -
	Extending Period of
	Confinement
	Any provider,
	who, for the purpose
	of claiming payment
	from the Systems
	files a Medicare
	claim with extended
	period of confinement:
	a)	By increasing the
		period of actual
		confinement of
		any patient; and/or
	b)	By continuously
		charting entries
		in the Doctor's
		Order, Nurse's
		Notes and
		Observations
		despite actual
		discharge or
		absence of the
		patients; and/or
	c)	By such other
		machinations.
4.	Filing of Multiple	P15,000 and	P23,000 and	P30,000 and
	Claims		suspension of	suspension of	revocation of
			accreditation	accreditation	accreditation.
	Any provider,	for 12 months.	for 18 months.	A recommendation
	who, for the purpose			shall be submitted to
	of claiming payment			the DOH for
	from the System,			cancellation
	files two or more			of license to
	Medicare claims for a			operate.
	patient who has been
	confined once but was
	made to appear as
	having been confined
	for two or more times
	and/or for two or
	more different
	illnesses.
5.	Violation Through	- do -	- do -	- do-
	Gross Negligence
	Any provider or
	beneficiary, who, by
	gross negligence,
	caused a serious
	violation shall be
	penalized for serious
	violations; if a less
	serious violation had
	been caused, shall be
	penalized for less
	serious violations.
	Gross Negligence
	is the want of even
	slight care and
	diligence as to raise
	a presumption that
	the practitioner or
	hospital or
	beneficiary at fault
	is conscious of the
	probable consequences
	or carelessness and is
	indifferent, or worse,
	oblivious to the danger
	of the injury to the
	person or property
	of others.
6.	Breach of Accreditation
	Warranties.

 

B. LESS SERIOUS VIOLATIONS

 

1.	Misrepresentation by
	Postdating of Claims
	Any provider,	P5,000 and	P10,000 and	P15,000
	who, for purposes of	suspension of	suspension of	and suspension
	claiming payment from	accreditation	accreditation	of accreditation
	the System, files a	for six	for eight	for eleven
	Medicare claim for	months.	months.	months.
	payment of services
	rendered not within
	60 days from the date
	of discharge of the
	patient but makes it
	appear to be so by
	changing, erasing,
	adding to the period
	of confinement or in
	any manner altering
	dates so as to defeat
	or conform to the 60
	days prescriptive
	period.
2.	Other
	Misrepresentations	P5,000 and	P10,000 and	P15,000 and
			suspension	suspension	suspension
	Any hospital or	of accreditation	of accreditation	of accreditation
	practitioner shall be	for six months	for eight months	for eleven months.
	liable for fraudulent
	practice by other
	misrepresentation
	when, for purposes of
	participation in the
	Medicare Program or
	claiming payment from
	the System, he/it
	furnishes false or
	incorrect information
	concerning any matter
	required by the
	Medicare Law and its
	Implementing Rules
	and Regulations not
	otherwise punishable
	under nos. 1, 2 and 3
	of serious violations.
3.	Violation of Accredited
	Bed Capacity
	Any hospital	- do -	- do -	- do -
	which for purposes of
	claiming payment from
	the System, files
	Medicare claims for
	patients confined in
	excess of the
	accredited bed
	capacity at any given
	time without
	explanation in the
	form and manner
	prescribed by the
	Commission.
4.	Unauthorized Operations
	Beyond Service Capability
	Any primary	- do -	- do -	- do -
	hospital which
	performs a surgical
	operation beyond its
	authorized capability
	shall be liable for
	unauthorized operations
	and shall be punished
	by the imposition of
	penalty for less serious
	violations except
	when the operation is
	done in emergency to
	save life or referral
	to a higher category
	hospital is physically
	impossible.
5.	Fabrication or Possession
	of Fabricated Medicare
	Forms and Supporting
	Documents
	Any provider who	P5,000 and	P10,000 and	P15,000 and
	is found preparing	suspension	suspension	suspension of
	claims with	of accreditation	of accreditation	accreditation
	misrepresentations or	for six months	for eight months	for eleven
	false entries or to			months
	be in possession of
	Medicare claim forms
	and other documents
	with false entries to
	support Medicare
	claims.
6.	Violative Acts
	Any provider or	- do -	- do -	- do -
	beneficiary shall be
	liable for violative
	acts by:
	a)	Failure or refusal
		to give the benefits
		due a qualified
		Medicare beneficiary;
		or
	b)	Charging the
		qualified Medicare
		patients for services
		or medicines which
		are legally
		chargeable to and
		covered by
		Medicare; or
	c)	Failure or refusal
		to refund to the
		beneficiary the
		payment received
		from the System
		within 30 days
		when the bill is
		fully paid in
		advance by the
		beneficiary; or
	d)	Failure or refusal
		to accomplish and
		submit the required
		PMCC Forms in
		connection with
		letter c; or
	e)	Deliberate failure
		or refusal to comply
		with the requisites
		of PD 1519 as
		amended and its
		Implementing Rules
		and Regulations,
		shall be penalized by
		the imposition of
		penalty for less
		serious violations.
	In paragraph (a), a
	mere refusal or
	failure to give
	benefits completes
	the violation.
	In paragraph (b),
	payment by the
	patient completes the
	violation.
	In paragraph (c),
	lapse of 30 days
	completes the
	violation.
	In paragraph (d), a
	mere refusal or
	failure to accomplish
	and submit the forms
	completes the violation.
7.	Penalty for Beneficiary
	Any beneficiary,	P5,000 and	P10,000 and	P15,000 and
	who, for the purpose	suspension	suspension	suspension
	of claiming Medicare	from availing	from availing	from availing
	benefits or	of Medicare	of Medicare	of Medicare
	entitlement thereto,	benefits	benefits	benefits
	commits any of the	for six months.	for eight months.	for eleven
	violations as			months.
	provided for in
	numbers one to five
	under serious
	violations and
	numbers one to six
	under less serious
	violations
	independently or in
	connivance with the
	hospital or practitioner.

 

C. LIGHT VIOLATIONS LPnLia

	Breach of Warranties
	of Accreditation
	by Practitioner or
	Beneficiary	Practitioners	Practitioners	Practitioners
	Any practitioner who,	P5,000 and	P5,000 and	P5,000 and
	shall be found to have	suspension	suspension	suspension
	made any breach of	of accreditation	of accreditation	of accreditation
	warranties of	for two months	for four months	for six months
	accreditation.
	Provided, that when	Beneficiaries	Beneficiaries	Beneficiaries
	the breach is in itself
	another violation or	P5,000 and	P5,000 and	P5,000 and
	results to another	suspension	suspension	suspension
	violation as provided in	from availing	from availing	from availing
	numbers one to five	of Medicare	of Medicare	of Medicare
	under serious violations	benefits for	benefits	benefits for six
	and numbers one to	one month.	for three months.	months.
	seven under less serious
	violations.

 

SECTION 6. Final Provisions. —

(a) When one single act constitutes or results to two or more violations, or when the violation is a necessary means of committing the other violations, the maximum penalty for the more serious violation shall be imposed.

(b) Pendency of a complaint before the Commission or a decision thereon shall not bar a separate independent criminal action and/or appropriate action before any board, office, tribunal or court against the erring respondent and vice-versa.

(c) When a hospital has ceased operations or the practitioner stops his practice before serving its/his penalty, execution shall be deferred, to be implemented when the same owner or medical director opens or operates a new hospital irrespective of the name or location or when the practitioner practices again. A spouse or a relative within the second degree of consanguinity of the hospital owner or medical director shall be presumed the alter-ego of the owner or medical director; Provided, that the dispositive part of the resolution requiring reimbursement of paid claim or denial of payment shall be immediately executory, notwithstanding the motion for reconsideration. iittam

(d) Violations and penalties shall prescribe as follows:

1. Violations punishable by revocation of accreditation or permanent revocation with recommendation to the DOH for cancellation of license to operate shall prescribe in five years.

Violations punishable by three or six months suspension or one year suspension and penalties therefore shall prescribe in three years.

2. The period of prescription of violations shall commence from the day the violation is discovered by the complainant and shall be interrupted by the filing of the complaint/memorandum and shall commence again if there is failure to act within a reasonable time which should not be more than one year.

The term of prescription shall not run when the erring respondent is not in the Philippines or when he/it cannot be served with summons due to his/its fault.

3. The period of prescription of penalties shall commence to run on the 31st day from the date the decision becomes final and executory.

SECTION 7. Applicability of this Rule. —

Complaints already filed with and under deliberation by the Hearing Committee shall be penalized in accordance with previous rules. (As amended by PMCC Res. Nos. 91-2281 and 93-2358) dIinis

RULE XIII

Implementing Provisions

SECTION 1. These amended rules and regulations shall take effect immediately as approved by law.