Legal basis, rationale, and objectives
- The circular is issued pursuant to new policies issued by the Corporation, including the Implementing Rules and Regulations of Republic Act No. 10606.
- The circular is anchored on Republic Act No. 10606, which amends the National Health Insurance Act of 1995 (Republic Act No. 7875, as amended).
- The circular also aligns with PhilHealth Circular No. 31 s. 2013 on “All Case Rates Policy No. 1—Governing Policies in the Shift of Provider Payment Mechanism from Fee for Service to Case-Payment Mechanism.”
- The rationale requires reforms in accrediting health care professionals so PhilHealth can pursue KaIusugan Pangkalahatan or Universal Health Care.
- The circular directs PhilHealth to render fast and efficient service by adopting simplified procedures and requirements consistent with Republic Act No. 9485 (Anti-Red Tape Act of 2007).
- The circular’s objectives include:
- Establishing a streamlined and effective process in accrediting health care professionals for the NHIP.
- Strengthening monitoring of PhilHealth accredited health care professionals.
- Recommending guidelines for health care institutions on their credentialing and privileging of health care professionals.
Coverage and key definitions
- The circular applies to all health care professionals currently participating in the NHIP and those with intention to participate.
- The circular applies to health care institutions where these health care professionals are affiliated.
- Covered health care professionals include:
- Physicians
- Dentists
- Midwives
- Other health care professionals as determined by PhilHealth
- Affiliation is the process by which a health care institution accepts a health care professional as part of its health human resource and grants practice privileges in the institution.
- Continuous accreditation is granted to accredited health care providers under basic participation, contingent on annual compliance with requirements prescribed by PhilHealth; it provides uninterrupted NHIP participation but may be withdrawn at any time based on PhilHealth rules.
- Credentialing is the process by which a health care institution obtains, verifies, and assesses the qualifications of a health care professional applying for affiliation.
- Performance Commitment (PC) is a document signed by health care professionals intending to participate in the Program that stipulates undertakings to provide complete and quality health services to PhilHealth members and dependents; it also reflects willingness to comply with PhilHealth policies on:
- benefits payment
- information technology
- data management and reporting
- referral
- among others
- Privileging is the process of giving appropriate practice privileges or benefits to health care professionals affiliated with a health care institution based on status, credentials, or qualifications.
Automatic accreditation and accreditation mechanics
- The following licensed professionals are automatically accredited and may participate in the NHIP, provided they submit the required documents (Annex A) including the signed Performance Commitment (PC), to the nearest PhilHealth office:
- Physicians
- Midwives
- Dentists
- Other professionals as determined by the Corporation
- The accreditation process for health care professionals must be streamlined through:
- Delegating to PhilHealth Regional Offices (PROs) the processing of all applications for accreditation and updating professionals’ profiles in the PhilHealth database.
- Delegating to the Chairperson of the Accreditation Committee authority to approve or deny Motions for Reconsideration, including acting on unresolved accreditation issues referred by PROs to the Committee.
- Institutionalizing continuous accreditation until withdrawn.
- Health care professionals may submit applications for initial accreditation and re-accreditation at any time of the year.
- For initial accreditation and re-accreditation, applicants may opt to pay the premium contribution for either:
- the remaining applicable quarter/s of the current year plus one year, or
- the remaining applicable quarter/s of the current year plus 2 years.
- The validity of accreditation for professionals applying for initial accreditation or re-accreditation:
- starts on the day of submission of complete requirements, and
- ends one day prior to the professional’s birth date.
- Accreditation fee payment and certificate of good standing requirements are removed:
- Payment of accreditation fee and certificate of good standing from the national association of professionals and/or specialty society of physicians are no longer required for accreditation application.
- Despite removal of these requirements, professional names must still be reflected in their association databases:
- names must be reflected in the database of the respective national association and/or specialty society declared in the PC.
- Accreditation is tied to association/society declarations:
- all HCPs must declare membership in a national association that is an Accredited Professional Organization by the PRC.
- physicians must declare membership in a specialty society recognized by the Philippine Medical Association.
- All health care professionals must undergo credentialing and privileging by their affiliated health care institution(s).
- Accredited professionals must sign and submit the PC for continuous accreditation:
- all currently accredited professionals must sign and submit the PC (Annex B) on subsequent applications for continuous accreditation.
- previously signed Warranties of Accreditation remain valid until renewal.
- professionals applying for re-accreditation and initial accreditation must submit and sign the PC upon the circular’s effectivity.
- Continuous accreditation timing and consequences:
- all currently accredited professionals must submit documentary requirements not later than 45 days prior to their birthday.
- failure to submit within the prescribed period results in withdrawal of continuous accreditation.
- Personal data updates:
- accredited professionals must inform PhilHealth immediately of changes in their Personal Data Record (Annex C) for database updating.
- Continuous accreditation validity period:
- for continuous accreditation applicants, validity is minimum of 1 year and maximum of 3 years.
- professionals may opt to pay premium contributions equivalent for 1 year, 2 years, or 3 years, which determines the accreditation validity granted.
- A PhilHealth Manual of Procedures and implementing guidelines must be issued to facilitate implementation.
Credentialing and privileging responsibilities
- Credentialing and privileging must be performed by the health care institutions where professionals are affiliated.
- Health care institutions must establish mechanisms to verify the capabilities, qualifications, and competence of health care professionals to ensure quality services to NHIP members and dependents.
- Roles of health care professionals:
- Health care professionals must submit credentials to their affiliated health care institutions.
- Health care professionals must ensure all credentials are legitimate, valid, and updated.
- Health care professionals must maintain good standing with PRC-recognized professional organizations.
- Roles of health care institutions (HCIs):
- All accredited HCIs must develop their own policies and guidelines for credentialing and privileging of affiliated professionals.
- HCIs may adopt policies endorsed by recognized accrediting bodies.
- HCIs must verify credentials from primary sources, including (among others):
- Medical Schools/Professional school accredited by the Commission on Higher Education
- Professional Regulatory Commission
- Training Hospital or Institution
- Specialty Board
- National Association of Health Care Professionals
- Other hospital affiliations of the health care professional
- HCIs must verify critical credentialing parameters including:
- current license
- education and training
- experience, ability, and current competence
- HCIs must conduct credentialing and privileging for all affiliated health professionals.
- HCIs must set the validity period for conferred privileges consistent with the professional’s license, unless privileges are suspended.
- HCIs must require affiliated health care professionals to update their PhilHealth accreditation as part of credentialing and privileging policies.
- HCIs must enjoin resident-physicians and contracted physicians to:
- become PhilHealth members, and
- get accredited.
- HCIs must keep records and agreements (or equivalent such as MOA) of all PRC-registered health care professionals who have undergone credentialing and privileging, including the practice privileges conferred.
- HCIs must allow PhilHealth to review all documents related to credentialing and privileging during monitoring of HCI surveys and whenever deemed necessary by the Corporation.
- HCIs must recognize the role of PRC-recognized national associations/specialty societies in continuing education and oversight of practice standards.
- Accredited HCIs must be accountable to PhilHealth for reports of noncompliance with PhilHealth policies, including quality-of-service issues.
- Violations of the Performance Commitment committed by professionals may be counted against the HCI where noted.
- After due process, HCIs must receive offense warnings and then face penalties or sanctions under PhilHealth’s implementing rules and regulations and other pertinent issuances.
- If professionals are also part of the credentialing and privileging committee/authority, they must sign an additional Performance Commitment provision declaring such arrangements to address potential conflicts of interest.
- Roles of PhilHealth:
- PhilHealth must verify the credentials and privileges of affiliated professionals of HCIs during performance monitoring and other quality assurance activities.
- PhilHealth must validate with issuing offices the authenticity of accreditation documents when deemed necessary.
- PhilHealth may withdraw an HCI’s accreditation when the HCI does not conduct credentialing and privileging of its professionals.
Withdrawal of continuous accreditation grounds
- Continuous accreditation is withdrawn by PhilHealth on any of the following grounds:
- Non-submission of all required documents within the prescribed filing period.
- Official declaration on quality/ethical issues endorsed by the national association governing the practice of the professional after due process.
- Official declaration on quality/ethical issues endorsed by the specialty society governing the practice of the physician after due process.
- Other reasons as determined by the Corporation.
Monitoring, peer review, offenses, and sanctions
- Accredited HCIs that committed to comply with PhilHealth rules and regulations must assist PhilHealth in monitoring the practices of their affiliated health care professionals.
- Monitoring findings about professionals—whether good or otherwise—must be reflected in the HCI profile and used as one basis for facility continuous accreditation and performance assessment.
- Accredited professionals must be subjected to the monitoring criteria in Section 47 item e of the new IRR, including monitoring for:
- over-utilization of services
- unnecessary diagnostic and therapeutic procedures and interventions
- irrational medication and prescriptions
- inappropriate referral practices
- grossly unjustified deviations from currently accepted standards of practice and/or guidelines or treatment protocols
- use of fake, adulterated or misbranded pharmaceuticals or unregistered drugs
- use of drugs other than those prescribed in the latest PNF and drugs for which exemptions were granted by the Board
- Additional violations include:
- unsafe practices (e.g., use of unsterilized instruments)
- unethical/questionable practice patterns
- PhilHealth must establish a feedback mechanism to inform health care professionals of monitoring findings.
- Professionals with negative monitoring findings must undergo peer review through the QAC.
- Peer review results may constitute an offense or violation of the professional’s Performance Commitment.
- After recommendation of the Committee, peer review results must also be reported to:
- the professional’s affiliate national association/specialty society
- PMA
- PRC
for other appropriate action.
- When such practice is observed, the HCI where it occurred must be tagged for the same offense.
- Three (3) offenses trigger sanctions consistent with the provisions stipulated in PC 54 s. 2012.
- Sanctions and penalties in the Performance Commitment for professionals must be applied as determined by the Corporation.
- All other violations of the Performance Commitment are handled accordingly:
- findings by the concerned PRO must be directly reported to their legal unit for appropriate action.
- professionals and HCIs where the violation was committed must be meted the same penalties as provided by existing laws, rules, and regulations, particularly those under Republic Act No. 7875, as Amended, and its Implementing Rules and Regulations.
Sanctions, repeals, and effect on prior issuances
- Violations of this circular, the Performance Commitment terms and conditions, and related PhilHealth circulars, office orders, and directives are handled under the pertinent provisions of Republic Act No. 7875, as amended by Republic Act No. 10606, and its Implementing Rules and Regulations.
- All previous PhilHealth issuances inconsistent or contrary to this circular are revised, modified, repealed, or rescinded accordingly.
- All provisions of existing issuances not affected by this circular remain valid and in effect.