EXECUTIVE ORDER NO. 195 August 13, 1994
PROVIDING A MEDICAL CARE PROGRAM TO FILIPINO OVERSEAS CONTRACT WORKERS AND THEIR DEPENDENTS AND PRESCRIBING THE MECHANISM THEREFOR
WHEREAS, it is the avowed policy of the government to provide adequate medical care services to the people;
WHEREAS, under the present policy, among the private working sector, only members of the Social Security System who are employed within the Philippines are compulsorily covered by the Philippine Medical Care Program (Law);
WHEREAS, studies show that a large number of overseas contract workers and their dependents, which comprise a significant portion of the Filipino population, are not assured of any medical care, in view of the lack of a program with a compulsory coverage;
WHEREAS, Filipino Overseas Contract Workers and their dependents must likewise be assisted in their medical care expenses consistent with the policy for their counterpart local workers and their dependents;
WHEREAS, the Philippine Medical Care Commission, the Department of Labor and Employment thru the Overseas Workers Welfare Administration and the Philippine Overseas Employment Administration, the Department of Foreign Affairs, and the Social Security System have enough facilities and manpower to ensure the effective and efficient medical care coverage of the Filipino Overseas Contract Workers and their dependents under a program similar to Program I of the Philippine Medical Care Plan;
NOW, THEREFORE, I, FIDEL V. RAMOS, President of the Philippines, by virtue of the powers vested in me by law, do hereby order:
Sec. 1. Filipinos recruited for employment abroad, herein referred to as Filipino Overseas Contract Workers or members, shall be compulsorily covered by the Philippine Medical Care Program pursuant to Section 31 of P.D. 1519, as amended, otherwise known as the Philippine Medical Care Law, without having to enroll themselves as SSS members.
Sec. 2. Dependents of Filipino Overseas Contract Workers shall also be covered with Medicare benefits through the membership of the latter.
Sec. 3. The premium contributions and benefits of the Filipino Overseas Contract Workers and their dependents shall be the same as those provided for SSS members under Program I of the Philippine Medical Care Plan.
Sec. 4. The compulsory coverage shall not apply to Filipino Overseas Contract Workers with existing coverage of the Philippine Medical Care Program acquired thru the SSS voluntary basis coverage pursuant to Section 9(b) of R.A. 1161, as amended, known as the SSS Law.
Sec. 5. The Rules and Regulations Implementing the Philippine Medical Care Commission, insofar as they are not inconsistent with this Order, shall also apply to the Medical Care Program coverage of the Filipino Overseas Contract Workers.
Sec. 6. The services, facilities, and the staff of the PMCC, SSS, DOLE thru OWWA and POEA, and the DFA shall be utilized for the implementation of this Order. Rules and Regulations defining the powers and functions of the said agencies and such other provisions necessary to implement this Order shall be adopted by the agencies thru a Memorandum of Agreement signed by the respective heads of Agencies.
Sec. 7. The OWWA shall provide the seed money necessary to start the operations of this program as shall be determined thru actuarial computations. The OWWA shall administer the funds of the program which shall be kept distinct and separate from all funds administered by the said agency.
Sec. 8. This Executive Order shall take effect immediately. lawphi1.net
Done in the City of Manila, this 13th day of August in the year of Our Lord, nineteen hundred and ninety four.
IMPLEMENTING THE RULES AND REGULATIONS OF THE MEDICAL CARE PROGRAM FOR FOCWS
Pursuant to Section 6 of Executive Order No. 195 PROVIDING A MEDICAL CARE PROGRAM TO FILIPINO OVERSEAS CONTRACT WORKERS (FOCWS) AND THEIR DEPENDENTS AND PRESCRIBING THE MECHANISM THEREFORE, the rules and regulations necessary to carry out the provisions and purposes of said Executive Order are hereby promulgated as follows:
RULE I. DEFINITION OF TERMS
Sec. 1. For purposes of these rules, the following terms shall be understood as:
a. PROGRAM - The Medical Care Program for FOCWs and their dependents.
b. ACCREDITED BED CAPACITY - Number of hospital beds authorized by the Commission to be used for Medicare purposes.
c. ADMINISTRATIVE ORDERS - Written promulgation in the form of PMCC Resolutions, Medicare Circulars, Memorandum Circulars, Special Orders, and Office Orders issued and duly circularized by the Commission and the OWWA 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, E.O. 195 and its implementing Rules and Regulations including Medicare accreditation warranties.
d. BENEFICIARIES - The Medicare members and their legal dependents.
e. CIRCUMSTANCE - Any attendant situation present in a given case which tends to exempt or aggravate the violation and liability of the respondent.
f. COMMISSION - The Philippine Medical Care Commission created under R.A. 6111, as revised.
g. CONFINEMENT - Admission and stay in a hospital due to illness or bodily injury, medical and/or surgical, requiring hospitalization.
h. DIAGNOSTIC/TREATMENT TERMINOLOGY - Terminology which conforms with the American Standard of Nomenclature of Diseases and Operations or the International Classification of Diseases.
i. EMERGENCY - Means medical and surgical conditions that threaten immediate loss of life when not attended to.
j. GSIS - The Government Service Insurance System created under Commonwealth Act. 186, as amended.
k. 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 services 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.
l. LEGAL DEPENDENT - The legal dependents of a member are: 1) the legitimate spouse who is not a Medicare Program I member and is not a member under this program; 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.
m. MEDICARE SERVICE BEDS - Hospital beds set aside for beneficiaries as may be prescribed by the Commission, and when occupied by a beneficiary, no fees beyond Medicare rates shall be charged to the account of the beneficiary.
n. 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.
o. MEMBER - Any Filipino Overseas Contract Worker who meets the following requirements:
1. not presently covered by the existing Philippine Medical Care Program by reason of his SSS/GSIS voluntary membership;
2. an OWWA member;
3. complied with requirements for enrollment as provided for in this Rules and Regulations.
p. OPERATING ROOM COMPLEX - Means emergency room, delivery room, operating room, and recovery room.
q. 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.
r. PRACTITIONER - Any doctor of medicine or dental medicine duly licensed/authorized to practice in the Philippine, a member in good standing of national association of government and privately-employed physicians or dentists whose membership comprises the majority of registered practicing physicians or dentist 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.
s. 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.
t. RELATIVE UNIT VALUE - Points assigned to surgical procedures according to their comparative complexity as adopted by the Commission.
u. 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.
v. SSS - The Social Security System created under R.A. 1161, as amended.
w. VIOLATION - Any act or omission constituting infraction of:
1. the provision 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. EO 195; and/or
6. orders issued by OWWA; and/or
7. other Medicare related laws, decrees, and regulations.
x. OWWA - The Overseas Workers Welfare Administration created under L.O.I. No. 537, P.D. 1694 and P.D. 1809 as amended.
y. POEA - The Philippine Overseas Employment Administration created under E.O. No. 797, as amended.
z. OEC or - Overseas Employment Certificate - a document issued to a contract worker legally processed by the POEA which serves as the worker's exit clearance upon departure.
aa. DFA - The Department of Foreign Affairs - organized under Executive Order No. 18 signed by President Manuel Roxas on September 16, 1946.
ab. OWWA Member - any legally deployed or documented worker whose OWWA contribution has been paid.
ac. OCW or Overseas Contract Worker - any person working or who has worked overseas under a valid contract.
ad. Balik-Manggagawa - all contract workers with re-entry visas or equivalent documents to enter and work in the host country and carry proof of arrival and departure in the same country as indicated in the passports.
RULE II. COVERAGE
Sec. 1. The nature and scope of coverage under the Medical Care Program for OCWs shall be compulsory on all the Filipino OCWs except those with existing coverage thru the SSS/GSIS voluntary membership program.
Sec. 2. REGISTRATION OF MEMBERSHIP - Registration/enrollment and recording of members shall be in accordance to the charter of the OWWA. Enrollees must meet the following requirements:
a. Those enrolling while within the country
1. have submitted properly accomplished enrollment form;
2. enrollment papers were processed thru POEA or its duly designated processing centers.
3. have paid corresponding premiums.
b On the job-site
1. have submitted properly accomplished registration form to OWWA or its duly designated collection center;
2. have paid corresponding premiums.
RULE III. BENEFITS
The benefits under the Executive Order 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).
Sec. 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 chemotheraphy, radiotheraphy, or hemodialysis similarly on an out-patient basis.
b. The member has paid at least one (1) annual contribution within the immediate three (3) month period prior to the first day of confinement.
c. The 45-day room and board allowance for the calendar year has not been consumed.
Sec. 2. TYPES OF BENEFITS - A beneficiary of the Program who is confined in a hospital on account of sickness or injury requiring hospitalization is entitled to confinement days per year as follows: a) Maximum of forty-five (45) days for members; and b) 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. ALLOWANCE FOR HOSPITAL ROOM AND BOARD PER DAY:
|
HOSPITAL CATEGORY |
|
PRIMARY |
SECONDARY |
TERTIARY |
|
P55/day |
P100/day |
P145/day |
b. ALLOWANCE FOR MEDICAL EXPENSE PER SINGLE PERIOD OF CONFINEMENT:
|
MEDICAL EXPENSE HOSPITAL CATEGORY BENEFITS PRIMARY SECONDARY TERTIARY |
|
1. |
ORDINARY CASES: |
|
Drugs & Medicine |
P595.00 |
P790.00 |
P1,015.00 |
|
X-ray/Lab/Others |
150.00 |
360.00 |
635.00 |
|
2. |
INTENSIVE CARE CASES: |
|
Drugs & Medicines |
P1,350.00 |
P1,620.00 |
P2,915.00 |
|
X-ray/Lab/Others |
325.00 |
830.00 |
1,260.00 |
|
3. |
CATASTROPHIC CASES: |
|
Drugs & Medicines |
- |
P3,650.00 |
P4,170.00 |
|
X-ray/Lab/Others |
- |
1,620.00 |
3,845.00 |
CATASTROPHIC CASES shall include the following:
1. Illnesses or injuries such as cancer cases requiring chemotheraphy and/or radiotheraphy, meningitis, encephalitis, cirrhosis of the liver, myocardial infraction, cerebrovascular 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.
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.
c. ALLOWANCE FOR PROFESSIONAL FEES
1. Medical/Dental Practitioner's fee of P55.00 per day for a General Practitioner and P80.00 for a Specialist but not to exceed:
a. For Ordinary Cases (per single period of confinement)
For General Practitioner P300.00
For Specialist 450.00
b. For Intensive/Catastrophic Cases (per single period of confinement)
For General Practitioner P450.00
For Specialist 750.00
2. Surgeon's fee not exceeding P7,080.00 shall be paid in accordance with the Relative Unit Value promulgated by the Commission.
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 similarly 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.
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.
3. Anesthesiologist's fee not exceeding thirty percent (30%) of the allowable Surgeon's fee. To be entitled to the above 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.
d. ALLOWANCE FOR OPERATING ROOM
FEE:
SURGICAL PROCEDURE HOSPITAL
WITH RELATIVE CATEGORY
UNIT VALUE OF
PRIMARY SECONDARY TERTIARY
-------------- ------------------- ---------------
0-5 P170.00 P295.00 P470.00
5.1-10 - 505.00 600.00
10.1 - above - 960.00 1550.00
e. SURGICAL FAMILY PLANNING PROCEDURES (STERILIZATION BENEFITS):
The following procedures are compensable under Medicare:
1. Vasectomy — P400.00
2. Tubal Ligation — P500.00
Sec. 3. EXCLUSIONS. The above benefits shall include expenses for the following:
a. Cosmetic surgery or treatment - surgery or treatment to preserve, enhance or restore comeliness, the primary purpose of which is to be beautify or bring about aesthetic effects;
b. Optometric services;
c. Psychiatric illness;
d. Services which are purely diagnostic in nature such as routine physical and medical examinations, executive check-ups, and similar medical diagnostic services;
e. Normal obstetrical delivery - any vaginal delivery which is not complicated by eclamsia, retained placenta, profuse bleeding requiring surgical intervention, breech extraction or similar complications.
Sec. 4. REQUIREMENTS FOR AVAILMENT OF MEDICARE BENEFITS:
a. A member of his legal dependent must present the original and true copy of the Medicare Eligibility Certificate to the hospital, the latter to be authenticated by the hospital and attached to the claim form.
b. The member shall furnish the OWWA with an updated list of his legal dependents as defined herein whenever necessary. In the case of a newly born dependent, a certified true copy of the birth certificate shall be submitted.
Sec. 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 are met.
b. The Medicare benefits to be granted shall be in accordance with the schedule provided for in these rules and regulations.
Sec. 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
Sec. 1. GENERAL PROVISIONS.
a. A member shall be free to choose from among the Medicare-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 forms.
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 OWWA for completion of supporting documents must be refiled within 120 days from its receipt by the hospital.
d. When the beneficiary has compiled 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 reimbursible by this Program. Provided, that in highly exceptional circumstances as may be determined by the OWWA, the beneficiary may be directly reimbursed of his or her expenses allowable under Rule III of these Rules.
e. The OWWA may deny or reduce any benefit provided by the Medical Care Program for OCWs 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 Program for OCWs.
In such cases, the member may be required to pay for the amount denied or reduced.
The OWWA may deny or reduce any benefit provided by the Medical Care Program for OCWs when the health provider:
1. Furnishes false or incorrect information concerning any matter required by the Rules and Regulations of this Program.
2. Fails to comply with any provision of the Rules and Regulations governing this 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 OWWA on the claims may be appealed to the Commission whose decision shall be final.
f. Primary hospitals are required to submit clinical records of patients in connection with their claims.
g. 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.
h. When the bed census as reflected by claims filed with OWWA exceeds its accredited bed capacity, such claims shall be accompanied by justification in writing, otherwise these shall not be given due course.
i. 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 hospitals shall be compensated only for a simple operations as listed by the Commission.
j. Verification of the status of the dependent by OWWA shall not suspend the usual processing of the claims and payment to the hospital and medical or dental practitioner without prejudice to whatever recourse OWWA may take against the member.
Sec. 2. PAYMENT OF MEDICARE BENEFITS OF MEMBERS ABROAD
a. REQUIREMENTS. The requirements shall include the following documents (in addition to the pertinent requirements for settlement of claims):
a. Statement of account and the official receipt of payment from the foreign hospital where the patient was confined;
b. Certification of the attending physician as to the final diagnosis, period of confinement, and services rendered.
b. MANNER OF PAYMENT. Payment shall be made to the beneficiary in Philippine Currency.
RULE V. CONTRIBUTIONS
Sec. 1. AMOUNT OF CONTRIBUTIONS. All members shall pay a uniform amount of Nine Hundred pesos (P900.00) only for a one (1) year program coverage. For initial payments, the amount shall cover the Medicare coverage of each member and his legal dependents starting the first day of the fourth month after payment. In the case of renewals of membership, the coverage of succeeding annual payments shall commence on the first day after expiration of the immediately preceding coverage, provided payment is made before said expiration. If payment is made after expiration, the rule on initial payments shall apply. Option to pay more than one (1) year of coverage shall be allowed, provided payment shall be made on an annual basis. The corresponding period of coverage shall be reflected in the Medicare Eligibility Certificate to be issued for the purpose.
Sec. 2. COLLECTION.
a. Enrollment or renewal of membership to the Program shall be a pre-requisite to the processing of OCW's employment documents and issuance of OEC.
b. OCWs on site shall pay their annual premium contributions directly to the OWWA or its designated collection centers.
c. Succeeding annual premium contributions shall be paid by the member or his dependent directly to the OWWA or its designated collection centers.
RULE VI. THE FUND
Sec. 1. a. The fund shall be known as the Overseas Contract Workers Health Insurance Fund (OCWHIF) which shall consist of all contributions and accrual to said fund including the seed money provided for this Program. The OCWHIF shall be kept distinct and separate from other funds administered by the OWWA.
Deposit, disbursement and investment of the fund shall be in the same manner and under the same conditions, requirements and safeguards applicable to the other funds being administered by the OWWA.
b. Use of the OCWHIF:
The fund shall be used for claims payments and operating expenses. The annual operating expenses shall not exceed 12% of the collection and accruals for the year.
RULE VII. SEED MONEY: TERMS AND CONDITIONS
Sec. 1. The OWWA shall provide the seed money necessary to start the operation of the program.
Sec. 2. The seed money shall be treated as a loan to the program bearing an interest rate of 5%, payable in two (2) years.
Sec. 3. Purposes of the seed money: The seed money shall be used to defray expenses for the following:
a. Projected Maintenance and Operating Expenses for the first quarter of operations such as:
a.1 Personnel Services
a.2 Maintenance and other Operating Expenses
b. Projected Capital Outlay
c. Pre-Operating Expenses
c.1 Launching
c.2 Program Promotions/Information Dissemination
c.3 Program and Staff Development to include
Inter-agency Technical meetings, Workshops, Fora, Training and other Similar Activities
RULE VIII. EFFECTS OF TERMINATION OF OVERSEAS EMPLOYMENT
Sec. 1. SEPARATION FROM EMPLOYMENT.
a. When the overseas employment of the member ceases he may elect to continue his Medicare Membership by giving a written notice to the OWWA and paying the same annual contribution.
b. The option to continue membership shall be allowed when exercised not later than within six (6) months following the lapse of his last annual Medicare coverage. If he fails to exercise the option within said period, the option is forfeited.
Sec. 2. TRANSFER OF MEMBERSHIP
When an OCW accepts a local private or government employment after termination of his overseas work, his medical care coverage under OWWA shall continue for the unexpired period corresponding to his premium payment. In case of dual membership, whatever medical care benefits available to him as a result of his GSIS/SSS membership must first be applied before applying the OWWA Medicare Program benefits. The OCW shall notify the OWWA of such change of employment.
RULE IX. ACCREDITATION
Sec. 1. The power to grant accreditation to provides as a pre-requisite for participation in this program shall be vested in the Philippine Medical Care Commission, and only such providers with existing accreditation may participate in this program except during such time that the accreditation is suspended or revoked.
Sec. 2. A hospital may be accredited if it satisfies the following pre-requisites:
a. It must be licensed by the Department of Health.
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.
c. It has been the operation for at least twelve (12) months prior to accreditation.
Sec. 3. 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.
Sec. 4. TERMS AND CONDITIONS:
a. The hospital must comply at all times during the period of accreditation with all 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).
Sec. 5. PERIOD OF ACCREDITATION. The period of accreditation shall be for two (2) years for hospitals and three (3) years for practitioner to take effect upon the approval by the Commission.
Sec. 6. ACCREDITATION FEES. For purpose of documentation and processing of applications for accreditation of Medicare providers, the Commission shall impose accreditation fees as may be circularized from time to time.
Sec. 7. COMMISSION OPTION. The Commission has the option to accredit a number of beds less than the authorized bed capacity per DOH license.
Sec. 8. 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 may be denied where there is a prima facie evidence of violation of the law and these rules and regulations.
RULE X. SUPERVISION AND/OR INSPECTION
Sec. 1. The Commission and/or the OWWA may exercise supervision through authorized representatives to perform such function.
Sec. 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 OWWA. Such representatives are likewise authorized to inspect the physical plant and equipment thereof.
Sec. 3. Whenever necessary the hospital shall allow the Commission and the OWWA or any of their representative to conduct interviews of Medicare patients and to verify records to determine whether laboratory, x-ray and diagnostic procedures were actually performed and whether medication/treatment were actually administered.
RULE XI. FINES, SUSPENSION OF MEMBERSHIP, BENEFITS AND ACCREDITATION
Sec. 1. JURISDICTION.
a. The OWWA shall have jurisdiction over violations committed by members and their dependents. As may be determined by the OWWA, the entitlement to benefits of any member-dependent found violating E.O. 195 and the related rules and regulations and administrative orders passed pursuant to said E.O. shall be suspended for a period not exceeding six (6) months and/or the member shall be fined not more than five thousand pesos (P5,000.00). The OWWA shall designate a person or persons who shall have the sole function of hearing complaints for violations under this section. Except as may be specifically provided or inconsistent, the term Hearing Committee as used in these Rules shall also refer to said designated person or persons.
b. Pursuant to the power to grant to accreditation to providers participating in this program, the Philippine Medical Care Commission shall have jurisdiction over all issues involving violations committed by providers and shall have the power to impose penalties such as fines and suspension or revocation of accreditation in the same manner and following the same procedures as in Program 1 of the present Philippine Medical Care Program.
Sec. 2. GROUNDS FOR COMPLAINTS. A complaint may be filed for any violation of the following:
a. the Philippine Medical Care Law;
b. Executive Order No. 195;
c. Rules implementing the Philippine Medical Care Law or Executive Order No. 195;
d. the warranties of accreditation;
e. other subsequent related laws, rules and regulations and administrative orders issued by the PMCC, OWWA and other duly constituted government agencies.
Sec. 3. WHO MAY FILE A COMPLAINT? The OWWA, the PMCC, POEA, DFA, or any person, may file a complaint against any person, provider, or any other juridical entity on the grounds as provided for in the preceding section.
Sec. 4. FORM OF COMPLAINT. The complaint shall be under oath except those filed by the aforesaid government agencies. 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 the evidence in support of the complaint.
A complaint may be withdrawn by the complainant in writing with the same formal requirements as the complaint. The complaint shall forthwith be dismissed unless for reasons of public interest, the OWWA in the case members or beneficiaries, or the PMCC in the case of providers, shall deem it necessary to prosecute, notwithstanding its withdrawn by the complainant.
Sec. 5. SUMMONS. Upon receipt of the complaint, summons shall be issued by the Hearing Committee either by personal service of 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 him/her/it.
Sec. 6. 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 of 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 allegation shall be deemed an admission.
Failure of the respondent as prescribed shall constitute a waiver of respondent's right to present evidence on his/her/its behalf and the Hearing Committee shall proceed to deliberate on/resolve the case.
RULE XII. HEARING/DELIBERATION PROCEDURES
Sec. 1. DELIBERATION/RESOLUTION OF THE CASE. 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/resolution. The Hearing Committee, in its deliberation or hearing, may render its findings in accordance with the facts presented in the pleadings or may, when deemed proper, issue an order setting the case for formal hearing.
Sec. 2. FORMAL 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 Committee or its duly authorized representative to compel attendance of witnesses of the production of books, papers and other records deemed necessary in connection with any question pending before the Hearing Committee.
Sec. 3. 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 the Chairman or any member of the Hearing Committee as to obstruct or interrupt the proceedings before the same, including disrespect toward said officials, 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 inappealable in court.
b. Indirect Contempt shall be dealt with by the Commission of Hearing Committee in the manner prescribed under Rule 71 of the Revised Rules of Court.
Sec. 4. 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.
Sec. 5. ORDER OF HEARING.
a. The lawyer 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.
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.
Sec. 6. 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/OWWA 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.
Sec. 7. MOTION FOR RECONSIDERATION. A party not satisfied with the decision of the Commission/OWWA 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 thereof.
The motion for reconsideration shall clearly point out the following grounds:
a. Error of law and/or relied upon by the party;
b. Newly discovered evidence or fact which could not with reasonable diligence by 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.
Sec. 8. FINALITY OF DECISION. The decision of the Commission/OWWA 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.
Sec. 9. APPEAL. The party who is not satisfied with the decision of the Commission/OWWA may appeal the same to the Office of the President in accordance with the procedure established under Administrative Code of 1987.
RULE XIII. EXECUTION/ENFORCEMENT OF DECISION
Sec. 1. A writ of execution shall be issued only upon a decision or order that finally disposes of the case or proceedings. Such execution shall be issued upon the expiration of the period to appeal therefrom if no appeal has been duly perfected, or if the appeal is denied.
Sec. 2. 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, OWWA shall be duly advised in writing of the same.
Sec. 3. Except when the respondent voluntarily pays the fine within fifteen (15) days before the finality of decision, the Committee may motu propio issue a write of execution for the purpose.
Sec. 4 . Where a respondent has a pending claim for payment from the OCW Health Insurance Fund (HIF), the fine imposed on such respondent may be enforced against the proceeds of such claim.
The OWWA, upon receipt of the decision of suspension, or revocation of accreditation and fine, shall immediately give notice as to the existence of such claim of the respondent. Upon order from the Commission, the OWWA shall remit to the Commission so much amount charged against the claim in satisfaction of the fine.
RULE XIV. 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 XV. PREVENTIVE SUSPENSION
Sec. 1. At any time after proper complaint has been filed 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 this Program if any of the following circumstances are present:
a. When the respondent has been previously found guilty of a violation as provided in this rules 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.
Sec. 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.
Sec. 3. The order, being interlocutory in nature, shall be inappealable but a petition for reconsideration thereof may be filed with the Commission/OWWA as the case may be 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.
Sec. 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.
Sec. 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 Rule XII.
RULE XVI. PENALTIES
In the promulgation of decision, order or ruling of penalty for violations of EO 195 and its Rules and Regulations, the Hearing Committee shall be guided as follows:
PART I. GENERAL PROVISIONS
Sec. 1. CLASSIFICATION OF VIOLATION ACCORDING TO GRAVITY.
a. Serious violations are those that carry a penalty of fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation of accreditation. In case of permanent revocation, a recommendation will be submitted to the Department of Health for cancellation of license to operate.
b. Less serious violations are those that carry a penalty of fine of Five Thousand Pesos (P5,000.00) or Fifteen Thousand Pesos (P15,000.00) and suspension from participation in the Medicare Program of six (6) months or one (1) year.
c. Special less serious violations are breach of warranties and violations committed by beneficiaries which carry a penalty of three (3) or six (6) months suspension for and a fine of Five Thousand Pesos (P5,000.00) and a suspension from availing of benefits for three (3) or six (6) months for latter.
Sec. 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 the violation(s).
a. Exempting Circumstances. The presence of force majeure shall exempt any hospital or practitioner or beneficiary from the liability for the violations except civil liability.
b. Aggravating Circumstances. The following circumstances shall increase the liability for the violation from the low to high:
1. Previous commission of two or more violations where the hospital, practitioner or beneficiary had been found guilty within a period of two (2) years.
2. Connivance;
3. Laxity or negligence in the preparation of Medicare claims, clinical records and supporting documents;
4. Willful operation without license and/or accreditation;
5. Machinations; and
6. Membership in the Commission or in any of its intermediaries.
Provided, that when the aggravating circumstance is a violation in itself, it shall be treated as such and shall not be considered as aggravating circumstance anymore.
Sec. 3. RULES FOR THE APPLICATION OR CIRCUMSTANCES:
a. The presence of the exempting circumstances regardless of any aggravating circumstances makes the violation non-penalizable except the denial of the claim or refund of claim already paid.
b. The presence of any aggravating circumstance shall increase the penalty of the violation from low to high.
Sec. 4. SCALE OF PENALTIES. The scale or gradation of penalty shall be as follows:
a. For Serious Violations:
High Penalty — a fine of Thirty Thousand Pesos
(P30,000.00) and permanent
revocation of accreditation. A
recommendation shall be submitted to
the Department of Health for
cancellation of license to operate.
Low Penalty — a fine of Thirty Thousand Pesos
(P30,000.00) and revocation of
accreditation with non-accreditation
for twenty-four (24) months.
b. For Less Serious Violations:
High Penalty — a fine of Fifteen Thousand Pesos P15,000.00) and one year suspension.
Low Penalty — a fine of Five Thousand Pesos(P5,000.00) and three (3) or six (6)months suspension.
c. Common Provisions. All penalties shall carry with them denial of payment of claim(s) in question and/or refund to the OWWA if already paid.
Suspension shall be carried out by the temporary cessation of the benefits of privilege under the Medicare Program.
Should be aggregate period of suspension to be imposed upon the provider on account of two or more violations exceed twenty-four (24) months, the high penalty for serious violations shall be imposed. In no case shall the penalty of fine exceed Thirty Thousand Pesos (P30,000.00).
A notice of suspension, for the benefit of beneficiaries, shall be posted indicating the period of suspension in such form and manner to be prescribed by the Commission.
Sec. 5. RULES FOR APPLICATION OF PENALTY.
a. Where there are no aggravating circumstances, the low penalty shall be imposed as follows:
1. For less serious violations - a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension.
2. For serious violations - a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four months.
3. For breach of warranties - three (3) months suspension.
4. For violation by beneficiaries - a fine of Five Thousand Pesos (P5,000.00) and three (3) months suspension of Medicare privilege.
b. When there is an aggravating circumstance, the high penalty shall be imposed as follows:
1. For less serious violations - a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension.
2. For serious violations - a fine of Thirty Thousand Pesos (P30,000.00) and permanent revocation of accreditation. A recommendation shall be submitted to the Department of Health for revocation of license to operate.
3. For breach of warranties - six (6) months suspension.
4. For violation by beneficiaries - a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension of Medicare privilege.
PART II. VIOLATIONS AND PENALTIES
Sec. 6. FRAUDULENT PRACTICES.
a. Misrepresentation.
1. Misrepresentation by Padding of Claims - Any provider who, for the purpose of claiming payment from the OWWA, files a Medicare claim for an amount more than the benefits actually used by adding drugs, medicines, procedures, services, supplies not actually done or given, shall be punished by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The padded claims shall be barred from payment or denied and, if paid, refunded.
2. Misrepresentation by Claiming for Non-Admitted Patients - any provider who, for the purpose of claiming payment for non-compensable out-patient illness from the OWWA, 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, shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claim shall be denied and, if paid, refunded.
3. Misrepresentation by Extending Period of Confinement - any provider who, for the purpose of claiming payment from the OWWA, 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.
c. By such other machinations, shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00) and revocation and accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claim shall be denied and, if paid, refunded.
4. Misrepresentation by Postdating of Claims - any provider, who, for purposes of claiming payment from the OWWA, files a Medicare claim for payment of services rendered not within sixty (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 sixty (60) days prescriptive period shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from the participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension. The claim shall be barred from payment and, if paid, refunded.
5. Other Misrepresentation - any hospital or practitioner shall be liable for fraudulent practice by other misrepresentation when, for purposes of participation in the Program or claiming payment from the OWWA, he/it furnishes false or incorrect information concerning any matter required by the E.O. 195 and its implementing Rules and Regulations not otherwise punishable under this, sub-sections (1) to (4) of this Rule, shall be penalized by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension. All claims shall be barred from payment, if paid, refunded.
b. Other Fraudulent Practices.
6. Filing of Multiple Claims - any provider who, for the purpose of claiming payment from the OWWA, files two or more Medicare claims for a patient who has been confined once shall be punished by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claims shall be denied and, if paid, refunded.
7. Violation of Accreditation Bed Capacity - any hospital which, for purposes of claiming payment, files Medicare claims for patients confined in excess of the accredited bed capacity at any given time without explanation in form and manner prescribed by the Commission shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension. Its excess claims shall not be paid.
8. Unauthorized Operations Beyond Service
Capability - any primary hospital which performs a surgical operation beyond its authorized capability shall be liable for unauthorized operations and shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension except when the operation is done in emergency to save life or referral to a higher category hospital is physically impossible.
9. Fabrication or Possession of Fabricated Medicare Forms and Supporting Documents - any provider who is found preparing claims with misrepresentations or false entries or to be in possession of Medicare claim forms and other documents with false entries to support claims shall be punished by a fine of Five Thousand Pesos (P5,000.00) and six (6) months suspension from participation in the Medicare Program or a fine of Fifteen Thousand Pesos (P15,000.00) and one (1) year suspension.
10. Fraudulent Acts - any provider or beneficiary shall be liable for fraudulent 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 OWWA within thirty (30) days when the bill is fully paid in advance by the beneficiary; or
d. failure or refusal to accomplish and submit the required forms in connection with letter c; or
e. deliberate failure or refusal to comply with the requisites of E.O. 195 and its Implementing Rules and Regulations,
shall be penalized by a fine of Thirty Thousand Pesos (P30,000.00) and revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation. In case of permanent revocation, a recommendation shall be submitted to the Department of Health for cancellation of license to operate. The claims shall be barred from payment and, if paid, refunded.
In paragraph (a), a mere refusal or failure to give benefits completes the violation.
In paragraph (b), payment of the patient completes the violation.
In paragraph (c), lapse of thirty (30) days completes the violation.
In paragraph (d), a mere refusal or failure to accomplish and submit the forms completes the violation.
Sec. 7. GROSS NEGLIGENCE.
a. Violation Through Gross Negligence - Any provider or beneficiary who, by gross negligence, caused a serious violation shall be penalized with the high penalty for serious violations; if a less serious violations had been caused, it shall be penalized with the high penalty 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.
Sec. 8. BREACH OF WARRANTIES OF ACCREDITATION - Any hospital or practitioner who shall be found to have made any breach of warranties of accreditation shall be penalized by three months or six (6) months suspension from participation in the Medicare Program; Provided, that when the breach is in itself another violation or results to another violation as provided in these Rules, it shall be penalized accordingly.
Sec. 9. PENALTY FOR BENEFICIARY - A beneficiary who, for purposes of claiming Medicare benefits or entitlement thereto, commits any of the violations as provided for in these Rules independently or in connivance with the hospital or practitioner shall be penalized by a fine of Five Thousand Pesos (P5,000.00) and suspension from availing of Medicare benefits for not more than six (6) months.
Sec. 10. 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 violation, the high penalty for the more serious violation shall be imposed.
b. Pendency of a complaint before the Commission of 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 resolution requiring reimbursement of paid claim or denial of payment shall be immediately executory, notwithstanding the motion for reconsideration.
d. Violations and penalties shall prescribe as follows:
1. Violations punishable by revocation of accreditation with non-accreditation for twenty-four (24) months or permanent revocation with recommendation to the Department of Health for cancellation of license to operate shall be prescribe in five (5) 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 if there is a failure to act within a reasonable time which should not be more than one (1) 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.
Sec. 11. These rules and regulations shall take effect upon publication in at least two (2) newspapers of national circulation.
November 14, 1994
The Lawphil Project - Arellano Law Foundation
