[ PHILHEALTH CIRCULAR NO. 10, S. 2008, March 24, 2008 ]
GROUNDS FOR NON-RENEWAL OF ACCREDITATION/NON-GRANTING OF RE-ACCREDITATION AS A RESULT OF PERFORMANCE MONITORING OF HEALTH CARE PROVIDERS
R.A. 7875 as amended by R.A. 9241 states "the Corporation shall have the authority to grant health care provider accreditation which confers privilege of participation in the program". Further, following are the provisions in the IRR of the National Health Insurance Program (NHIP), to wit:
This Circular shall provide a scheme to ensure the following:
1. Strict compliance of all Philhealth policies, rules and regulations on accreditation, quality assurance, claims processing and fraud detection and prevention.
2. Establish offenses and violations as a result of monitoring the performance of accredited health care institutions and professionals and scheme that will immediately forewarn therein non-compliance with accreditation requirements and violations of the policies, rules and regulations.
3. Safeguard the Corporation against unscrupulous health care institutions and professionals who are unworthy of participation in the National Health Insurance Program and are not qualified for renewal of accreditation.
4. Maintain high quality standards of care being rendered to members by accredited health care institutions and professionals
The following are the grounds for non-renewal of accreditation/non-granting of re-acceditation as a result of the performance monitoring;
I. Health care providers considered as outlier/violator on the safeguards on practices provided in Rule XII, Section 76, IRR of R.A. 7875 as amended by R.A. 9241 to wit:
II. Breach of Warranties of Accreditation (please find attached)*
III. Non-compliance with PHIC policies and regulations to include but not limited to the following:
a. Non-issuance of official receipts to PhilHeaith or to members which contra venes PHIC Circular 24 s-2005 which mandates issuance of official receipts
b. Absence of physical and/or registered nurse during inspection or monitoring of health care institutions
c. Non-serving of meals
d. Incidence of double-filing of claims, overlapping claims as supported by the report generated through the n-claims.
e. Non-submission of mandatory monthly hospital report
f. Filing of claims for cataract procedures performed during medical missions inconsistent with PHIC Circular 19, s-2007
g. Hospitals found with the same deficiency/deficiencies or multiple deficien- : cies for 2 consecutive years during inspection**
h. Providers which have been penalized thrice (3) or more based on the decision rendered by the Arbitration Department of this Corporation**
i. Family confinements defined as "record of at least 4 family members purportedly confined at the same time" except during epidemics as confirmed by DOH/concerned agency and other exclusions as determined by Standards and Monitoring Department**
j. Weekend confinements defined as "pattern/record of at least 50% of claims with weekend confinements meaning admitted Friday or Saturday and discharged on Sunday or early Monday**
Except those which have been specifically qualified (** ), the foregoing grounds for non-renewal/non-granting of accreditation shall be acted upon as follows:
Any violation committed and/or determined shall be considered as an offense and accumulation of three (3) offenses not necessarily of the same nature shall be considered as a third offense, hence, reccomended for non-renewal/non-granting of accreditation.
PROCESS SCHEME
These reports shall be referred to the Standards and Monitoring Department (SMD) for validation. Once validated as an offense, the SMD shall forward a report to the Accreditation Department which shall then be responsible in collating, updating and recording of the offenses committed by health care providers. The Accreditation Department shall also be responsible in forwarding the recommendation of non-renewal of accreditation/non-grantinq of re-accreditation to the Accreditation Committee.
B. DECISION
The Accreditation Committee shall act on the recommendation accordingly and may render any of the following decisions subject to the approval of the President and CEO.
a) Grant renewal/re-accreditation
b) Deny renewal/re-accreditation
Health care providers which have not been accorded or denied of accreditation in view of the abovementioned grounds shall be precluded from initiating new application for accreditation within one (1) year from the time the accreditation was not renewed/granted or to a period to be determined by the Corporation.
This circular shall take effect fifteen (15) days after publication in broadsheets of national circulation. All other issuances inconsistent herein are hereby repealed and modified accordingly.
Adopted: 24 March 2008
(SGD.) LORNA O. FAJARDO
Acting President & CEO
* Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City.
* Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City.
Section 63 (a) The Corporation shall determine the period of accreditation and reserves the right to issue or deny accreditation after an evaluation of the capability and integrity of the health care providerAs such, in order for the Corporation to monitor the compliance and performance of the accredited health care providers and following the IRR which provides under Rule XII Section 76 for the Corporation to develop and implement a performance monitoring system for all health care providers which shall provide safeguards against practices enumerated therein, Philhealth Board Resolution (PBR) 1048, s. 2008 created the Performance Assessment and Monitoring System (PAMS). Moreover, this system was created because of the fact as stated in the said PBR "whereas it has come to the knowledge of the Corporation through the exercise of its quality assurance and quasi-judicial power that there is an alarming increase of unscrupulous health care institutions and professionals who have learned to circumvent the provisions of the law and its implementing rules and have incessantly undermined the authority of the Corporation in the administration of the NHIF and the Program".
Section 64 (a) The Corporation shall determine the period of accreditation and reserves the right to issue or deny accreditation after an evaluation of the capability and integrity of the health care professional
Section 71 Grounds for denial/non-reinstatement of accreditation (a)non-com-piiance with any or ail of the rights and conditions of accreditation; (b) non-compliance with the safeguards provided under these Rules
This Circular shall provide a scheme to ensure the following:
1. Strict compliance of all Philhealth policies, rules and regulations on accreditation, quality assurance, claims processing and fraud detection and prevention.
2. Establish offenses and violations as a result of monitoring the performance of accredited health care institutions and professionals and scheme that will immediately forewarn therein non-compliance with accreditation requirements and violations of the policies, rules and regulations.
3. Safeguard the Corporation against unscrupulous health care institutions and professionals who are unworthy of participation in the National Health Insurance Program and are not qualified for renewal of accreditation.
4. Maintain high quality standards of care being rendered to members by accredited health care institutions and professionals
The following are the grounds for non-renewal of accreditation/non-granting of re-acceditation as a result of the performance monitoring;
I. Health care providers considered as outlier/violator on the safeguards on practices provided in Rule XII, Section 76, IRR of R.A. 7875 as amended by R.A. 9241 to wit:
a. over-and under-utilization of servicesFurther, violations such as the following are also grounds for non-renewal/non-granting of re-accreditation
b. unnecessary diagnostic and therapeutic procedures and interventions
c. irrational drug use
d. inappropriate referral practices
e. gross, unjustified deviations from currently accepted parctice guidelines or treatment protocols
f. use of fake, adulterated or misbranded pharmaceuticals or unregistered drugs.
g. use of drugs other than those recognized in the PNDF and those for which exemptions were granted by the Board.
h. withholding/denial of benefits/services to members and dependents.
a. Utilization of unsafe and inappropriate instruments in the performance/practice of proceduresThese outliers/violators shall be determined by the Peer Review Committee (PERC) and reported as such by the Standards and Monitoring Department.
b. Unethical/Mismanagement/Questionable practice patterns
II. Breach of Warranties of Accreditation (please find attached)*
III. Non-compliance with PHIC policies and regulations to include but not limited to the following:
a. Non-issuance of official receipts to PhilHeaith or to members which contra venes PHIC Circular 24 s-2005 which mandates issuance of official receipts
b. Absence of physical and/or registered nurse during inspection or monitoring of health care institutions
c. Non-serving of meals
d. Incidence of double-filing of claims, overlapping claims as supported by the report generated through the n-claims.
e. Non-submission of mandatory monthly hospital report
f. Filing of claims for cataract procedures performed during medical missions inconsistent with PHIC Circular 19, s-2007
g. Hospitals found with the same deficiency/deficiencies or multiple deficien- : cies for 2 consecutive years during inspection**
h. Providers which have been penalized thrice (3) or more based on the decision rendered by the Arbitration Department of this Corporation**
i. Family confinements defined as "record of at least 4 family members purportedly confined at the same time" except during epidemics as confirmed by DOH/concerned agency and other exclusions as determined by Standards and Monitoring Department**
j. Weekend confinements defined as "pattern/record of at least 50% of claims with weekend confinements meaning admitted Friday or Saturday and discharged on Sunday or early Monday**
Except those which have been specifically qualified (** ), the foregoing grounds for non-renewal/non-granting of accreditation shall be acted upon as follows:
| First Offense | - HCP's shall be notified of the violation |
| Second Offense | - Stem Warning with a notation that another violation shall be basis for recommendation of non-renewal/non-granting of accreditation |
| Third Offense | - Recommendation of non-renewal/non-granting of accreditation |
Any violation committed and/or determined shall be considered as an offense and accumulation of three (3) offenses not necessarily of the same nature shall be considered as a third offense, hence, reccomended for non-renewal/non-granting of accreditation.
PROCESS SCHEME
| A. | REPORTING | |
| Information/reports shall be reffered by the following: | ||
| a) | Office of the Senior Vice-President for health Finance Policy Sector | |
| b) | Office of the Vice-President for Quality Assurance Group | |
| c) | Standards and Monitoring Department | |
| d) | Peer Review Committee | |
| e) | Fact-Finding Investigation and Enforcement Department | |
| f) | PhilHealth Regional Offices | |
| g) | Arbitration Department | |
| h) | Other sources such as but not limited to stakeholders, societies/organizations agencies |
These reports shall be referred to the Standards and Monitoring Department (SMD) for validation. Once validated as an offense, the SMD shall forward a report to the Accreditation Department which shall then be responsible in collating, updating and recording of the offenses committed by health care providers. The Accreditation Department shall also be responsible in forwarding the recommendation of non-renewal of accreditation/non-grantinq of re-accreditation to the Accreditation Committee.
B. DECISION
The Accreditation Committee shall act on the recommendation accordingly and may render any of the following decisions subject to the approval of the President and CEO.
b) Deny renewal/re-accreditation
Health care providers which have not been accorded or denied of accreditation in view of the abovementioned grounds shall be precluded from initiating new application for accreditation within one (1) year from the time the accreditation was not renewed/granted or to a period to be determined by the Corporation.
This circular shall take effect fifteen (15) days after publication in broadsheets of national circulation. All other issuances inconsistent herein are hereby repealed and modified accordingly.
Adopted: 24 March 2008
Acting President & CEO
* Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City.
* Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City.