FOURTEENTH CONGRESS OF THE REPUBLIC 
} 
OF THE PHILIPPINES 
1 
First Regular Session 
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SENATE 
S. B. No. 
Introduced by SENATOR EaGARDO J. ANGARA 
EXPLANATORYNOTE 
The bill seeks to strengthen 
ility of the Philippine Health 
Insurance Corporation (PhilHealth) 
ffective implementation of the 
National Health Insurance Progr 
) against the incidence of 
fraudulent activities. It primarily 
cifically define offenses and 
penalties as well as the emerging ab 
and unethical practices to be 
imposed against erring health care 
ployers and members. This 
bill also seeks to increase the amount o 
the existing “P10,OOO.OO to 
P50,OOO.OO” to “P50,OOO to P100,OOO.OO” 
a discretion on the part of the 
PhilHealth to impose such fine or suspe 
from three (3) months to the 
whole term of accreditation or rev0 
ditation, or both such fine 
and suspension or revocation again 
alth care provider. On the 
aspect of erring employers, it will 
nalties to be imposed for 
failure to register and/or deducth 
n of their employees and 
that the violations may also be cri 
The billions of pesos in benefit pay ent are really irresistible to some 
unscrupulous health care providers. Thou % there is no statistical and hard 
data to measure the amount of fraudulent claims, it is imperative to define 
and criminalize the abuses and unethica practices of erring health care 
providers before they become an inevitab t e threat to the NHI Fund. The 
abuses and unethical practices are getti g sophisticated, evolving to new 
methods and techniques of violations alon 1 
every generation of social health 
insurance. 
With regard to the employers, Phil ealth will not only focus on the 
filing of cases on their violations. More i portantly, PhilHealth considers 
them as big partners in the effective an efficient implementation of the 
NHIP as they are the biggest contributors o the NHI Funds. Given their big 
role and responsibility, employers shou 1 
d be reminded that the non- 
registration, non-deduction and/or non-remittance of 
the 
premium 
contributions of their employees will lead to the collapse of the Program. 
Hence, in order to balance both the interest of PhilHealth and the employers, 
this bill proposes the imposition of interes and surcharges of three percent 
(3%) per month or at any rate as may be f h ed by the Corporation in case of 
delay in the remittances of premiums. This is to avoid the litigious process of 
going to court for the settlement of their aeears and clear the name of their 
company in the quickest possible way. This provision is copied verbatim from 
the provisions of RA No. 8282 or the SSS Acit of 1997. 


Moreover, RA No. 7875, as amended by RA No. 9241 failed to provide 
PhilHealth the enforcement power and authority against any erring health 
care providers and employers. In order to specifically address this very 
urgent concern, it is therefore proposed to vest PhilHealth with visitorial and 
police powers to ensure the effective implementation of the NHIP and to 
protect the NHI Fund from being indiscriminately dissipated through 
fraudulent activities, abuses and unethical practices from unscrupulous 
health care providers and employers. 
Lastly, anticipating the vital role of the informal sector, PhilHealth 
already devised innovative approaches in extending the coverage from this 
category. It conceptualized the Kalusugang Sigurado at Abot-Kaya sa 
PhilHealth Insurance (KASAPI) which targeted the organized groups for the 
group enrollment of its members in the Program. The successful 
implementation of this scheme has led to the rapid increase of NHIP 
members most especially from this sector. Thus, it would be of the best 
interest to expand the current representation of the self-employed in the 
PhilHealth Board of Directors as stated in the law to embody the entire 
informal sector. The aforesaid sector is very diverse which include not only 
the self-employed sub-groups but also encompasses the small-scale, 
occasional members such as all types of street vendors and sometimes those 
who are informally employed in the formal enterprises. Additionally, it is also 
being endorsed to change the representation of the employed sector to formal 
sector for more clarity and to distinguish it from the informal sector. 
In view of the foregoing, the approval of the bill is earnestly sought. 
RA 
$enator 


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FOURTEENTH CONGRESS OF THE REPUBLIC 
} 
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.
,
 
I 
0 
i.' i 
OF THE PHILIPPINES 
First Regular Session 
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Introduced by SENATOR EDGARDO J. ANGARA 
AN ACT DEFINING THE OFFENSES AND ABUSES AGAINST THE 
NATIONAL HEALTH INSURANCE PROGRAM ("IP) 
AND PROVIDING 
PENALTIES AND SANCTIONS THEREFOR, AMENDING FOR THE 
PURPOSE ARTICLE X OF REPUBLIC ACT NO. 7875 OTHERWISE 
KNOWN AS THE NATIONAL HEALTH INSURANCE ACT 
OF 1995 AS AMENDED BY RA 9241 AND 
FOR OTHER PURPOSES 
Be it enacted by the Senate and the House of Representatives in Congress 
assembled: 
SECTION 1. Section 28 of Republic Act No. 7875 as amended by RA 
9241 is hereby amended to read as follows: 
SEC. 18. The Board of Directors. - 
a) Composition - The Corporation shall be governed by a 
Board of Directors hereinafter referred to as the Board, 
composed of eleven members as follows: 
The Secretary of Health; 
The Secretary of Labor and Employment or his 
representative; 
The Secretary of the Interior and Local Government or his 
representative; 
The Secretary of Social Welfare and Development or his 
representative; 
The President of the Corporation; 
A representative of the FORMAL [labor] sector; 
A representative of employers 
The SSS Administrator or his representative; 
The GSIS General Manager or his representative; 
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The Vice Chairperson for the basic sector of the National 
Anti-Poverty Commission or his representative; 
A representative of Filipino Overseas Workers TO BE 
ENDORSED BY DULY RECOGNIZED NATIONAL 
ASSOCIATION OF OVERSEAS FILIPINO WORKERS; 
A representative of the INFORMAL 
[Self-employed] 
sector; and 
A representative of health care providers to be endorsed 
by the national association of health care institutions and 
medical professionals. 
The Secretary of Health shall be the ex officio 
Chairperson while the President of the Corporation shall be the 
Vice Chairperson of the Board. 
b) 
Appointment and Tenure - The President of the 
Philippines shall appoint the Members of the Board upon the 
recommendation of the Chairman of the Board and in 
consultation with the sectors concerned. Members of the Board 
shall have a term of four (4) years each, renewable for a 
maximum of two (2) years, except for members whose terms 
shall be co-terminous with their respective positions in 
government. Any vacancy in the Board shall be filled in the 
manner in which the original appointment was made and the 
appointee shall serve only the unexpired term of his predecessor. 
c) Meetings and Quorum - The Board shall hold regular 
meetings at least once a month. Special meetings may be 
convened at the call of the Chairperson or by a majority of the 
members of the Board. The presence of a majority of all the 
members shall constitute a quorum. In the absence of the 
Chairperson and Vice Chairperson, a temporary presiding 
officer shall be designated by the majority of the quorum. 
d) Allowances and Per Diems - The members of the Board 
shall receive a per diem for every meeting actually attended 
subject to the pertinent budgetary laws, rules and regulations 
on compensation, honoraria and allowances. 
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SECTION 2. Article X of the same Act is also hereby amended to read 
as follows: 
Article X. OFFENSES AND Penalties 
SEC. 44. OFFENSES OF INSTITUTIONAL HEALTH CARE 
PROVIDERS- 
SEC. 44-A. PADDING OF CLAIMS - ANY HEALTH CARE 
PROVIDER WHO, FOR THE PURPOSE OF CLAIMING PAYMENT 
FROM THE NHIP, FILES A CLAIM FOR BENEFITS WHICH ARE 
IN EXCESS OF THE BENEFITS ACTUALLY PROVIDED BY 
ADDING DRUGS, MEDICINES, SUPPLIES, PROCEDURES AND 
SERVICES, SHALL BE PENALIZED WITH A FINE OF NOT LESS 
THAN FIFTY THOUSAND PESOS (P50,OOO.OO) BUT NOT MORE 
THAN ONE HUNDRED THOUSAND PESOS (PlOO,OOO.OO) OR 
SUSPENSION OF ACCREDITATION FROM THREE (3) MONTHS 
TO THE WHOLE TERM OF ACCREDITATION OR REVOCATION 
OF 
ACCREDITATION, 
OR 
BOTH 
SUCH 
FINE 
AND 
SUSPENSION/REVOCATION, AT THE DISCRETION OF THE 
CORPORATION. 
SEC. 44-B. CLAIMS FOR SERVICES NOT RENDERED 
AND / OR CONFINEMENTS OF NON-ADMITTED PATIENTS - 
ANY HEALTH CARE PROVIDER WHO, FOR THE PURPOSE OF 
CLAIMING BENEFIT REIMBURSEMENT FROM THE NHIP: 
A. 
MAKES IT APPEAR 
THAT 
THE PATIENT IS 
ACTUALLY 
CONFINED AND 
I OR 
PROVIDED 
PHILHEALTH-COVERED SERVICES IN THE HEALTH 
CARE INSTITUTION / FACILITY OR 
USES SUCH OTHER MACHINATIONS THAT WOULD 
RESULT 
IN 
CLAIMS 
FOR 
SERVICES 
NOT 
RENDERED/GIVEN 
B. 
SHALL BE PENALIZED WITH A FINE OF NOT LESS THAN FIFTY 
THOUSAND PESOS (P50,OOO.OO) BUT NOT MORE THAN ONE 
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HUNDRED THOUSAND PESOS (PlOO,OOO.OO) OR SUSPENSION OF 
ACCREDITATION FROM THREE (3) MONTHS TO THE WHOLE 
TERM 
OF 
ACCREDITATION 
OR 
REVOCATION 
OF 
ACCREDITATION, OR BOTH SUCH FINE AND SUSPENSION I 
REVOCATION, AT THE DISCRETION OF THE CORPORATION. 
SEC. 44-C. EXTENDING PERIOD OF CONFINEMENT - 
ANY HEALTH CARE PROVIDER WHO, FOR THE PURPOSE OF 
CLAIMING PAYMENT FROM THE NHIP, FILES A CLAIM WITH 
EXTENDED PERIOD OF CONFINEMENT BY 
A. 
INCREASING 
THE 
PERIOD 
OF 
ACTUAL 
CONFINEMENT OF ANY PATIENT; 
B. 
CONTINUOUSLY 
CHARTING 
ENTRIES IN THE 
DOCTOR'S 
ORDER, 
NURSES 
NOTES 
AND 
OBSERVATION DESPITE ACTUAL DISCHARGE OR 
ABSENCE OF THE PATIENTS; OR 
USING SUCH OTHER MACHINATIONS THAT WOULD 
RESULT IN THE UNNECESSARY EXTENSION OF 
CONFINEMENT. 
C. 
SHALL BE PENALIZED WITH A FINE OF NOT LESS THAN FIFTY 
THOUSAND PESOS (P50,OOO.OO) BUT NOT MORE THAN ONE 
HUNDRED THOUSAND PESOS (PlO0,OOO.OO) OR SUSPENSION OF 
ACCREDITATION FROM THREE (3) MONTHS TO THE WHOLE 
TERM 
OF 
ACCREDITATION 
OR 
REVOCATION 
OF 
ACCREDITATION, OR BOTH SUCH FINE AND SUSPENSION / 
REVOCATION, AT THE DISCRETION OF THE CORPORATION. 
SEC. 44-D. POST-DATING OF CLAIMS - ANY HEALTH 
CARE 
PROVIDER 
WHO, 
FOR 
PURPOSES 
OF CLAIMING 
PAYMENT FROM THE NHIP, FILES A CLAIM FOR PAYMENT OF 
SERVICES RENDERED NOT WITHIN SIXTY (60) CALENDAR 
DAYS FROM THE DATE OF DISCHARGE OF THE PATIENT OR 
SUCH OTHER PRESCRIPTIVE PERIODS AS THE CORPORATION 
MAY ISSUE BUT MAKES IT APPEAR SO BY CHANGING, 
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ERASING, ADDING TO THE PERIOD OF CONFINEMENT OR IN 
ANY MANNER ALTERING DATES SO AS TO CONFORM WIT THE 
ADOPTED PRESCRIPTIVE PERIOD, SHALL SUFFER A FINE OF 
NOT LESS THAN FIFTY THOUSAND PESOS (P50,OOO.OO) BUT NOT 
MORE THAN ONE HUNDRED THOUSAND PESOS (PlOO,OOO.OO) 
OR SUSPENSION OF ACCREDITATION FROM THREE (3) 
MONTHS TO THE WHOLE TERM OF ACCREDITATION OR 
REVOCATION OF ACCREDITATION, OR BOTH SUCH FINE AND 
SUSPENSION / REVOCATION, AT THE DISCRETION OF THE 
CORPORATION. 
ALL CLAIMS FOR REIMBURSEMENT SHALL BE FILED 
WITHIN A PERIOD OF SIXTY (60) CALENDAR DAYS FROM THE 
DATE OF DISCHARGE OF THE PATIENT. OTHERWISE, THE 
CLAIM WILL BE DENIED. SUCH PERIOD MAY BE EXTENDED 
FOR SUCH CAUSES AS MAYBE DETERMINED BY THE 
CORPORATION. 
SEC. 44-E. MISREPRESENTATION BY FURNISHING 
FALSE OR INCORRECT INFORMATION - ANY HEALTH CARE 
PROVIDER SHALL BE LIABLE FOR FRAUDULENT PRACTICE 
WHEN, FOR THE PURPOSE OF PARTICIPATION IN THE NHIP 
OR CLAIMING PAYMENT THEREFROM, IT FURNISHES FALSE 
OR INCORRECT INFORMATION CONCERNING ANY MATTER 
REQUIRED BY THIS ACT. IT SHALL BE PENALIZED WITH A 
FINE OF NOT LESS THAN FIFTY THOUSAND PESOS (P50,OOO.OO) 
BUT NOT MORE THAN ONE HUNDRED THOUSAND PESOS 
(PlOO,OOO.OO) 
OR SUSPENSION OF ACCREDITATION FROM 
THREE (3) MONTHS TO THE WHOLE TERM OF ACCREDITATION 
OR REVOCATION OF ACCREDITATION, OR BOTH SUCH FINE 
AND SUSPENSION/REVOCATION, AT THE DISCRETION OF THE 
CORPORATION. 
WHERE SUCH MISREPRESENTATION LEADS TO DAMAGE 
TO THE CORPORATION, THE PENALTY SHALL BE THE 
MAXIMUM FINE AND REVOCATION OF ACCREDITATION. 
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SEC. 44-F. FILING OF MULTIPLE CLAIMS - ANY 
HEALTH CARE PROVIDER WHO, FOR THE PURPOSE OF 
CLAIMING PAYMENT FROM THE NHIP, FILES TWO OR MORE 
CLAIMS FOR A PATIENT FOR THE SAME CONFINEMENT OR 
ILLNESS, OR MAKES IT APPEAR THAT THE PATIENT HAD 
BEEN CONFINED FOR TWO OR MORE TIMES AND/OR FOR TWO 
OR MORE DIFFERENT ILLNESSES SHALL BE PENALIZED WITH 
A FINE OF NOT LESS THAN FIFTY THOUSAND PESOS 
(P50,OOO.OO) BUT NOT MORE THAN ONE HUNDRED THOUSAND 
PESOS (PlO0,OOO.OO) 
OR SUSPENSION OF ACCREDITATION 
FROM THREE (3) MONTHS TO THE WHOLE TERM OF 
ACCREDITATION OR REVOCATION OF ACCREDITATION, OR 
BOTH SUCH FINE AND SUSPENSION / REVOCATION, AT THE 
DISCRETION OF THE CORPORATION. 
SEC. 
44-G. 
UNJUSTIFIED 
ADMISSION 
BEYOND 
ACCREDITED 
BED 
CAPACITY - ANY 
HEALTH 
CARE 
INSTITUTION WHICH, FOR THE PURPOSE OF CLAIMING 
PAYMENT FROM THE NHIP, FILES CLAIMS FOR PATIENTS 
CONFINED IN EXCESS OF THE ACCREDITED BED CAPACITY AT 
ANY GIVEN TIME WITHOUT JUSTIFICATION IN THE FORM AND 
MANNER PRESCRIBED BY THE CORPORATION SHALL SUFFER 
A FINE OF NOT LESS THAN FIFTY THOUSAND PESOS 
(P50,OOO.OO) BUT NOT MORE THAN ONE HUNDRED THOUSAND 
PESOS (PlOO,OOO.OO) 
OR SUSPENSION OF ACCREDITATION 
FROM THREE (3) MONTHS TO THE WHOLE TERM OF 
ACCREDITATION OR REVOCATION OF ACCREDITATION, OR 
BOTH SUCH FINE AND SUSPENSION/REVOCATION, AT THE 
DISCRETION OF THE CORPORATION. 
SEC. 
44-H. 
CLAIMS 
FOR 
UNAUTHORIZED 
SER VICES/PROCED URES 
PERFORMED 
BEYOND 
ACCREDITATION CAPABILITY OF THE HEALTH CARE 
INSITUTIONrnACILITY 
- 
ANY 
HEALTH 
CARE 
INSTITUTION/FACILITY WHICH PERFORMS HEALTH CARE 
SERVICES/PROCEDURES 
BEYOND 
ITS 
AUTHORIZED 
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CAPABILITY SHALL SUFFER A FINE OF NOT LESS THAN FIFTY 
THOUSAND PESOS (P50,OOO.OO) BUT NOT MORE THAN ONE 
HUNDRED THOUSAND PESOS (PlOO,OOO.OO) OR SUSPENSION OF 
ACCREDITATION FROM THREE (3) MONTHS TO THE WHOLE 
TERM 
OF 
ACCREDITATION 
OR 
REVOCATION 
OF 
ACCREDITATION, OR BOTH SUCH FINE AND SUSPENSION/ 
REVOCATION, AT THE DISCRETION OF THE CORPORATION, 
EXCEPT WHEN 
SUCH SERVICES 
WERE 
DONE 
IN AN 
EMERGENCY SITUATION / CONDITION 
TO SAVE LIFE AND 
REFERRAL 
TO 
A 
HIGHER 
CATEGORY 
PROVIDER 
IS 
PHYSICALLY IMPOSSIBLE. 
SEC. 
44-1. 
FABRICATION 
OR 
POSSESSION 
OF 
FABRICATED FORMS AND SUPPORTING DOCUMENTS - ANY 
HEALTH CARE PROVIDER WHO IS FOUND PREPARING CLAIMS 
WITH MISREPRESENTATIONS OR FALSE ENTRIES, OR TO BE IN 
POSSESSION OF CLAIM FORMS AND OTHER DOCUMENTS 
WITH FALSE ENTRIES, SHALL SUFFER A FINE OF NOT LESS 
THAN FIFTY THOUSAND PESOS (P50,OOO.OO) BUT NOT MORE 
THAN ONE HUNDRED THOUSAND PESOS (PlOO,OOO.OO) 
OR 
SUSPENSION OF ACCREDITATION FROM THREE (3) MONTHS 
TO THE WHOLE TERM OF ACCREDITATION OR REVOCATION 
OF ACCREDITATION, OR BOTH SUCH FINE AND SUSPENSION I 
REVOCATION, AT THE DISCRETION OF THE CORPORATION. 
SECTION 44-5. ABUSES AND UNETHICAL PRACTICES - 
ANY HEALTH CARE PROVIDER SHALL BE LIABLE FOR THE 
FOLLOWING ABUSES AND UNETHICAL PRACTICES: 
A. 
UNSAFE OR DANGEROUS PRACTICES AS MAY BE 
DETERMINED BY THE CORPORATION; 
IRRATIONAL OR UNNECESSARY DRUG USE; 
UNNECESSARY PERFORMANCE OF DIAGNOSTIC OR 
B. 
C. 
, 
THERAPEUTIC PROCEDURES; 
D. 
CHARGING OR COLLECTING FROM A MEMBER AN 
AMOUNT IN EXCESS OF THE BENEFITS INCLUDING 


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3s 
THOSE COVERED BY CAPITATION OR GLOBAL 
BUDGETS FOR PHILHEALTH-COVERED SERVICES 
AND SUPPLIES WHICH PROHIBITS CHARGING OF 
OUT-OF-POCKET PAYMENT INCLUDING OUTSIDE 
PURCHASES 
OF MEDICINES, 
SUPPLIES 
AND 
HEALTH CARE SERVICES THAT ARE INCLUDED IN 
THE BENEFIT; 
E. 
ENROLLMENT AND / OR RECRUITMENT OF A 
PERSON FOR THE SOLE PURPOSE OF CLAIMING 
BENEFITS AND I OR PAYMENT OF PREMIUM OF A 
MEMBER BEFORE PROVIDING HEALTH 
CARE 
SERVICES TO HIM I HER, EXCEPT WHEN THE 
PATIENT OR MEMBER IS ITS EMPLOYEE OR THE 
OWNERS RELATIVE WITHIN THE FOURTH CIVIL 
DEGREE OF CONSANGUINITY OR AFFINITY; AND, 
F. 
ALL SUCH OTHER ABUSES AND UNETHICAL 
PRACTICES AS MAY BE DETERMINED BY THE 
CORPORATION. 
SAID HEALTH CARE INSTITUTION SHALL BE PENALIZED 
WITH A FINE OF NOT LESS THAN FIFTY THOUSAND PESOS 
(P50,OOO.OO) BUT NOT MORE THAN ONE HUNDRED THOUSAND 
PESOS (PlO0,OOO.OO) 
OR SUSPENSION OF ACCREDITATION 
FROM THREE (3) MONTHS TO THE WHOLE TERM OF 
ACCREDITATION OR REVOCATION OF ACCREDITATION, OR 
BOTH SUCH FINE AND SUSPENSIONIREVOCATION, AT THE 
DISCRETION OF THE CORPORATION. 
SEC. 44-K. OTHER FRAUDULENT ACTS - ANY HEALTH 
CARE 
PROVIDER 
SHALL ALSO 
BE 
LIABLE 
FOR 
THE 
FOLLOWING FRAUDULENT ACTS: 
A. 
MAKING IT APPEAR THAT THE PATIENT SUFFERED 
FROM COMPENSABLE ILLNESS OR UNDERWENT A 
COMPENSABLE PROCEDURE; 
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B. 
C. 
D. 
E. 
I?. 
G. 
FAILURE OR REFUSAL TO GIVE THE BENEFITS 
DUE TO QUALIFIED MEMBERSDFPENDENTS; 
CHARGING QUALIFIED PATIENTS FOR MEDICINES 
AND/OR 
SERVICES 
WHICH 
ARE 
LEGALLY 
CHARGEABLE TO AND COVERED BY THE NHIP; 
FAILURE OR REFUSAL TO REFUND TO THE 
MEMBER THE PAYMENT RECEIVED FROM THE 
NHIP 
WHEN THE 
HOSPITAL 
CHARGES AND 
PROFESSIONAL 
FEES 
ARE 
FULLY 
PAID 
IN 
ADVANCE BY THE MEMBER WITHIN A PERIOD OF 
THIRTY (30) DAYS FROM THE DATE OF RECEIPT OF 
REFUND CHECK FROM THE CORPORATION; 
FAILURE OR REFUSAL TO ACCOMPLISH AND 
SUBMIT THE REQUIRED FORMS IN CONNECTION 
WITH LETTER D.; 
FAILURE OR REFUSAL TO PROVIDE THE MEMBERS 
WITH THE REQUIRED FORMS FOR DIRECT FILING 
OF CLAIMS, BILLING STATEMENTS, OFFICIAL 
RECEIPTS 
AND 
OTHER 
DOCUMENTS 
REQUIRED/NECESSARY FOR FILING OF CLAIMS; OR 
DELIBERATE FAILURE OR REFUSAL TO COMPLY 
WITH THE REQUIREMENTS UNDER THIS ACT. 
SEC. 
44-L. 
BREACH 
OF 
THE WARRANTIES OF 
ACCREDITATION - ANY INSTITUTIONAL HEALTH CARE 
PROVIDER WHO COMMITS ANY BREACH OF THE WARRANTIES 
OF ACCREDITATION SHALL SUFFER A FINE OF NOT LESS 
THAN FIFTY THOUSAND PESOS (P50,OOO.OO) BUT NOT MORE 
THAN ONE HUNDRED THOUSAND PESOS (PlO0,OOO.OO) OR 
SUSPENSION OF ACCREDITATION FROM THREE (3) MONTHS 
TO THE WHOLE TERM OF ACCREDITATION OR REVOCATION 
OF 
ACCREDITATION, 
OR 
BOTH 
SUCH 
FINE 
AND 
SUSPENSION/REVOCATION, AT THE DISCRETION OF THE 
CORPORATION. 
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SEC. 44-M. OTHER VIOLATIONS - ANY OTHER WILLFUL 
OR NEGLIGENT ACT OR OMISSION OF THE INSTITUTIONAL 
HEALTH CARE PROVIDER IN VIOLATION OF THIS ACT WHICH 
TENDS TO UNDERMINE OR DEFEAT THE OBJECTIVES OF THE 
NHIP SHALL BE CONSIDERED AS BREACH OF WARRANTIES. 
SEC. 44-N. CRIMINAL LIABILITY - IN ADDITION, A 
CRIMINAL COMPLAINT SHALL BE FILED AGAINST THE 
OFFICIALS OF THE ERRING INSTITUTIONAL HEALTH CARE 
PROVIDER BEFORE THE APPROPRIATE OFFICE OF THE 
PROSECUTOR FOR VIOLATIONS OF THIS ACT AND/OR THE 
REVISED PENAL CODE. 
SEC. 45. OFFENSES OF HEALTH CARE 
PROFESSIONALS - 
SEC. 45-A. MISREPRESENTATION BY FALSE OR 
INCORRECT 
INFORMATION 
- 
ANY 
HEALTH 
CARE 
PROFESSIONAL 
SHALL 
BE 
LIABLE 
FOR 
FRAUDULENT 
PRACTICE WHEN, FOR PURPOSES OF PARTICIPATION IN THE 
NHIP OR CLAIMING PAYMENT FROM THE CORPORATION, 
FURNISHES 
FALSE 
OR 
INCORRECT 
INFORMATION 
CONCERNING ANY MATTER REQUIRED BY THIS ACT SHALL 
SUFFER A FINE OF NOT LESS THAN FIFTY THOUSAND PESOS 
(P50,OOO.OO) BUT NOT MORE THAN ONE HUNDRED THOUSAND 
PESOS (PlOO,OOO.OO) OR SUSPENSION OF ACCREDITATION 
FROM THREE (3) MONTHS TO THE WHOLE TERM OF 
ACCREDITATION OR REVOCATION OF ACCREDITATION, OR 
BOTH SUCH FINE AND SUSPENSION/REVOCATION, AT THE 
DISCRETION OF THE CORPORATION. 
SEC.45-B. 
BREACH 
OF 
THE 
WARRANTIES 
OF 
ACCREDITATION - ANY HEALTH CARE PROFESSIONAL 
FOUND 
TO HAVE 
COMMITTED ANY BREACH OF THE 
WARRANTIES OF ACCREDITATION SHALL SUFFER A FINE OF 
NOT LESS THAN FIFTY THOUSAND PESOS (P50,OOO.OO) BUT NOT 
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MORE THAN ONE HUNDRED THOUSAND PESOS (PlO0,OOO.OO) 
OR SUSPENSION OF ACCREDITATION FROM THREE (3) 
MONTHS TO THE WHOLE TERM OF ACCREDITATION OR 
REVOCATION OF ACCREDITATION, OR BOTH SUCH FINE AND 
SUSPENSION/REVOCATION, AT THE DISCRETION OF THE 
CORPORATION. 
SEC. 45-C. ABUSES AND UNETHICAL PRACTICES - ANY 
HEALTH CARE PROVIDER SHALL BE LIABLE FOR THE 
FOLLOWING ABUSES AND UNETHICAL PRACTICES: 
A. 
B. 
C. 
D. 
E. 
F. 
PERFORMANCE OF PROCEDURES BEYOND THOSE 
ALLOWED BY THE HEALTH CARE PROFESSIONAL'S 
QUALIFICATIONS AND TRAINING EXCEPT WHEN 
UNDER 
THE 
DIRECT 
SUPERVISION 
OF 
A 
QUALIFIED HEALTH CARE PROFESSIONAL; 
UNSAFE OR DANGEROUS PRACTICES AS MAY BE 
DETERMINED BY THE CORPORATION 
IRRATIONAL OR UNNECESSARY DRUG USE; 
UNNECESSARY PERFORMANCE OF DIAGNOSTIC OR 
THERAPEUTIC PROCEDURES; 
CHARGING OR COLLECTING FROM A MEMBER AN 
AMOUNT IN EXCESS OF THE BENEFITS INCLUDING 
THOSE COVERED BY CAPITATION OR GLOBAL 
BUDGETS FOR PHILHEALTH-COVERED SERVICES 
AND SUPPLIES WHICH PROHIBITS CHARGING OF 
OUT-OF-POCKET PAYMENT INCLUDING OUTSIDE 
PURCHASES 
OF MEDICINES, 
SUPPLIES 
AND 
HEALTH CARE SERVICES THAT ARE INCLUDED IN 
THE BENEFIT; 
ENROLLMENT 
AND/OR 
RECRUITMENT 
OF A 
PERSON FOR THE SOLE PURPOSE OF CLAIMING 
BENEFITS AND/OR PAYMENT OF PREMIUM OF A 
MEMBER BEFORE PROVIDING HEALTH 
CARE 
SERVICES TO HIMIHER, 
EXCEPT WHEN THE 
PATIENT OR MEMBER IS HIS/HER EMPLOYEE OR 
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RELATIVE WITHIN THE FOURTH CIVIL DEGREE OF 
CONSANGUINITY OR AFFINITY; AND, 
G. 
ALL SUCH OTHER ABUSES AND 
UNETHICAL 
PRACTICES AS MAY BE DETERMINED BY THE 
CORPORATION. 
SAID 
HEALTH 
CARE 
PROFESSIONAL 
SHALL 
BE 
PENALIZED WITH A FINE OF NOT LESS THAN FIFTY 
THOUSAND PESOS (P50,OOO.OO) BUT NOT MORE THAN ONE 
HUNDRED THOUSAND PESOS (PlOO,OOO.OO) OR SUSPENSION OF 
ACCREDITATION FROM THREE (3) MONTHS TO THE WHOLE 
TERM 
OF 
ACCREDITATION 
OR 
REVOCATION 
OF 
ACCREDITATION, 
OR 
BOTH 
SUCH 
FINE 
AND 
SUSPENSION/REVOCATION, AT THE DISCRETION OF THE 
CORPORATION. 
SEC. 45-D. OTHER VIOLATIONS - ANY OTHER WILLFUL 
OR NEGLIGENT ACT OR OMISSION OF THE HEALTH CARE 
PROFESSIONAL IN VIOLATION OF THIS ACT WHICH TENDS TO 
UNDERMINE OR DEFEAT THE OBJECTIVES OF THE NHIP 
SHALL BE CONSIDERED AS BREACH OF WARRANTIES. 
SEC. 45-E. CRIMINAL LIABILITY - IN ADDITION, A 
CRIMINAL COMPLAINT SHALL BE FILED AGAINST AN ERRING 
HEALTH CARE PROFESSIONAL BEFORE THE APPROPRIATE 
OFFICE OF THE PROSECUTOR FOR VIOLATIONS OF THIS ACT 
AND/OR THE REVISED PENAL CODE. 
SEC. 46. OFFENSES OF MEMBERS- 
SEC. 46-11, FRAUDULENT ACTS - ANY MEMBER WHO, 
FOR 
PURPOSES 
OF 
CLAIMING 
NHIP 
BENEFITS 
OR 
ENTITLEMENT THERETO, SHALL COMMIT ANY OF THE 
OFFENSES PROVIDED FOR BY THIS ACT, INDEPENDENTLY OR 
IN CONNIVANCE WITH THE HEALTH CARE PROVIDER, SHALL 
SUFFER A FINE OF FIVE THOUSAND PESOS (P5,OOO) AND 
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SUSPENSION FROM AVAILMENT OF NHIP BENEFITS FOR NOT 
LESS THAN THREE (3) MONTHS BUT NOT MORE THAN SIX (6) 
MONTHS. 
SEC. 46-B. CRIMINAL LIABILITY - IN ADDITION, A 
CRIMINAL COMPLAINT SHALL BE FILED AGAINST THE 
MEMBER BEFORE THE OFFICE OF THE PROSECUTOR FOR THE 
ABOVE 
VIOLATIONS 
WHICH 
CARRY 
A 
PENALTY 
OF 
IMPRISONMENT OF NOT LESS THAN SIX (6) MONTHS BUT NOT 
MORE THAN ONE (1) YEAR. 
“SEC. [44] 47. [Penal Provisions. - Any violation of the 
provisions of this Act, after due notice and hearing, shall suffer the 
following penalties:]-OFFENSES OF EMPLOYERS- 
[A fine of not less than Ten thousand pesos (P 10,000) nor more 
than Fifty thousand pesos (P50,OOO) in case the violation is committed 
by the hospital management or provider. In addition, its accreditation 
shall be suspended or revoked from three (3) months to the whole term 
of accreditation: Provided, however; That recidivists may not anymore 
be accredited as a participant of the program; 
A fine of not less than Five hundred pesos (P500) nor more than 
Five thousand pesos (P5,OOO) and imprisonment of not less than six (6) 
months nor more than one (1) year in case the violation is committed 
by the member.] 
Where the violations consist of failure or refusal to [deduct 
contributions from the employee’s compensation or to remit the same 
to the Corporation, the penalty shall be a fine of not less than Five 
hundred pesos (P500) but not more than One thousand pesos (P1,OOO) 
multiplied by the total number of employees employed by the firm and 
imprisonment of not less than six (6) months but not more than one (1) 
year: Provided, further, That in the case of self-employed members, 
failure to remit one’s own contribution shall be penalized with a fine of 
not less than five hundred pesos (P500) but not more than One 
thousand pesos (Pl,OOO).] REGISTER EMPLOYEES, OR TO DEDUCT 
CONTRIBUTIONS FROM THE EMPLOYEES COMPENSATION 
AND/OR REMIT THE SAME TO THE CORPORATION, THE 
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PENALTY SHALL BE A FINE OF FIVE THOUSAND PESOS 
(P5,OOO.OO) 
MULTIPLIED 
BY 
THE 
TOTAL 
NUMBER 
OF 
EMPLOYEES OF THE FIRM AND IMPRISONMENT OF NOT LESS 
THAN SIX (6) YEARS AND ONE (1) DAY BUT NOT TO EXCEED 
TWELVE (12) YEARS. 
Any employer or any officer authorized to collect contributions 
under this Act who, after collecting or deducting the monthly 
contributions from his employee’s compensation, fails to remit the said 
contributions to the Corporation within thirty (30) days from the date 
they become due shall be presumed to have misappropriated such 
contribution and shall suffer the penalties provided for in Article 315 of 
the Revised Penal Code. 
Any employer who shall deduct directly or indirectly from the 
compensation of the covered employees or otherwise recover from them 
his own contribution on behalf of such employees shall be punished by 
a fine [not exceeding] OF [One] FIVE thousand pesos (P[l] 5,000) 
multiplied by the total number of employees employed by the firm[or] 
AND imprisonment FOR not [exceeding one (l)] LESS THAN SIX (6) 
YEARS AND ONE DAY BUT NOT TO EXCEED TWELVE (12) 
years.[or both fine and imprisonment, at the discretion of the Court.] 
If the act or omission penalized by this Act be committed by an 
association, partnership, corporation or any other institution, its 
managing directors or partners or president or general manager, or 
other persons responsible for the commission of the said act shall be 
liable for the penalties provided for in this Act and other laws for the 
offense. 
Any employee of the Corporation who receives or keeps funds or 
property belonging, payable or deliverable to the Corporation, and who 
shall appropriate the same, or shall take or misappropriate or shall 
consent, or through abandonment or negligence shall permit any other 
person to take such property 
or funds wholly or partially, shall 
likewise be liable for misappropriation of funds or property and shall 
suffer imprisonment of not less than six (6) years and not more than 
twelve (12) years and a fine of not less than Ten thousand pesos 
(P10,OOO) nor more than Twenty thousand pesos (P20,OOO). Any 
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shortage of the funds or loss of the property upon audit shall be 
deemed prima facie evidence of the offense. 
CRIMINAL ACTION ARISING FROM A VIOLATION OF THE 
PROVISIONS OF THIS ACT MAY BE COMMENCED BY THE 
CORPORATION OR THE EMPLOYEE CONCERNED EITHER 
UNDER THIS ACT OR IN APPROPRIATE CASES UNDER THE 
REVISED PENAL CODE: PROVIDED, THAT SUCH CRIMINAL 
ACTION MAY BE FILED BY THE CORPORATION IN THE CITY OR 
MUNICIPALITY WHERE: THE VIOLATION WAS COMMITTED OR 
IN PROPER COURTS IN METRO MANILA, AT THE OPTION OF 
THE CORPORATION. 
“SEC. 48. GENER..AL PROVISIONS - 
SEC. 
48-A. 
1MITIGATING 
AND 
AGGRAVATING 
CIRCUMSTANCES - THE 
FOLLOWING 
CIRCUMSTANCES 
SHALL AFFECT THE GRAVITY OF THE VIOLATION AND THE 
LIABILITY 
OF THE ERRING HEALTH 
CARE PROVIDER, 
MEMBER, AND EMPLOYER: 
A. 
MITIGATING CIRCUMSTANCES - THE FOLLOWING 
CIRCUMSTANCES SHALL MITIGATE THE LIABILITY 
OF THE RESPONDENT: 
1. VOLUNTARY ADMISSION OF GUILT; 
2. GOOD TRACK RECORD; 
3. FIRST OFFENSE; AND 
4. SUCH OTHER CIRCUMSTANCES AND 
CONSIDEUTIONS AS MAY BE DETERMINED BY 
THE CORPORATION. 
B. AGGRAVATING CIRCUMSTANCES - THE FOLLOWING 
CIRCUMSTANCES SHALL AGGRAVATE THE LIABILITY 
OF THE RESPONDENT 
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1. PREVIOUS CONVICTION OF AN OFFENSE, AS 
PROVIDED FOR IN THIS ACT; 
2. CONNIVANCE AND/OR CONSPIRACY WITH AN 
OFFICER 012 EMPLOYEE OF THE CORPORATION TO 
FACILITATE OR COVER-UP THE COMMISION OF 
THE VIOLATION; 
3. GROSS NEGLIGENCE; AND, 
4. SUCH 
OTHER 
CIRCUMSTANCES 
AND/OR 
CONSIDEMTIONS AS MAY BE DETERMINED BY 
THE CORPORATION. 
SEC. 48-B. APPLICATION OF CIRCUMSTANCES IN THE 
IMPOSITION OF PENALTIES - 
A. 
B. 
C. 
THE PRESENCE OF MITIGATING CIRCUMSTANCE 
WITHOUT ANY AGGRAVATING CIRCUMSTANCE 
SHALL LIMIT THE IMPOSABLE PENALTY TO ITS 
MINIMUM. 
WHEN THERE IS NEITHER MITIGATING NOR 
AGGRAVATING CIRCUMSTANCE, THE IMPOSABLE 
PENALTY SHALL BE BETWEEN THE MINIMUM AND 
THE MAXIMUM OF THE APPLICABLE PENALTY FOR 
THE OFFENSE COMMITTED, AT THE DISCRETION 
OF THE CORPORATION. THE SAME SHALL APPLY 
WHEN BOTH MITIGATING AND AGGRAVATING 
CIRCUMSTANCE ARE PRESENT. 
THE 
PRESENCE 
OF 
ANY 
AGGRAVATING 
CIRCUMSTANCE 
WITHOUT 
THE 
MITIGATING 
CIRCUMSTANCE SHALL INCREASE THE PENALTY 
OF THE OFFENSE TO ITS MAXIMUM. 
SEC. 48-C. COMMON PROVISIONS - ALL PENALTIES FOR 
OFFENSES COMMITTElD BY HEALTH CARE PROVIDERS AND 
MEMBERS SHALL CARRY WITH THEM DENIAL OF PAYMENT 
OF CLAIMIS IN QCJESTION AND/OR 
REFUND 
TO THE 
CORPORATION, IF ALREADY PAID. 
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IF THE PENALTY OF SUSPENSION IMPOSED AGAINST A 
HEALTHCARE PROVIDER EXCEEDS THE VALIDITY OF THE 
CURRENT ACCREDITATION, THE RENEWAL OR THE RE- 
ACCREDITATION OF THE LATTER SHALL NOT BE ACTED UPON 
UNTIL THE FULL TERM OF THE SUSPENSION IMPOSED HAS 
BEEN SERVED OR LIFTED. FOR THIS PURPOSE, THE PERIOD 
COVERING THE EXPIRATION OF ACCREDITATION AND THE 
START OF THE EFFECTIVITY OF THE RENEWAL AND/OR RE- 
ACCREDITATION SHALL BE CONSIDERED AS PART OR 
CONTINUATION OF THE SUSPENSION. SUSPENSION SHALL 
BE CARRIED OUT BY THE TEMPORARY CESSATION OF THE 
BENEFITS OR PRIVILEGES UNDER THE NHIP. 
SHOULD THE AGGREGATE PERIOD OF SUSPENSION TO 
BE IMPOSED UPON THE PROVIDER ON ACCOUNTS OF TWO OR 
MORE VIOLATIONS EXCEED TWENTY-FOUR (24) MONTHS, THE 
MAXIMUM IMPOSABLE PENALTY SHALL BE EXACTED. 
IN ALL CASES WHEREIN A DECISION IS RENDERED 
AGAINST A HEALTH CARE PROVIDER, THE DEPARTMENT OF 
HEALTH (DOH), PROFESSIONAL REGULATIONS COMMISSION 
(PRC) AND/OR OTHER CONCERNED AGENCIES SHALL BE 
FURNISHED WITH A COPY OF THE SAME FOR INFORMATION 
AND/OR APPROPRIATE ACTION. 
A NOTICE OF SUSPENSION FOR THE INFORMATION OF 
THE PUBLIC SHALL BE POSTED IN CONSPICUOUS PLACES 
AND / OR IN THE INSTITUTION CONCERNED INDICATING THE 
PERIOD OF SUSPENSION IN SUCH FORM AND MANNER TO BE 
PRESCRIBED BY THE CORPORATION. 
A HEALTH CARE PROVIDER WHO AT THE TIME OF TRIAL 
FOR AN OFFENSE ENTJMERATED HEREIN SHALL HAVE BEEN 
PREVIOUSLY CONVICTED BY FINAL JUDGMENT FOR ANY 
OFFENSE UNDER THIS ACT MAY NO LONGER BE ACCREDITED 
AS PARTICIPANT OF THE NHIP. 
SEC. 49. FINAL PROVISIONS - 
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SEC. 49-A. PROSECUTION OF OFFENSES - OFFENSES 
DEFINED UNDER SECTIONS 44s, 45s, 46s and 47s HEREOF, 
SHALL BE PROSECUTED IN REGULAR COURTS OF JUSTICE OF 
COMPETENT 
JURISDICTION 
WITHOUT 
PREJUDICE 
TO 
ADMINISTRATIVE ACTION THAT MAY BE INSTITUTED BY THE 
CORPORATION UNDER EXISTING LAWS. 
SEC. 49-B. FILING OF COMPLAINX - THE FILING OF 
COMPLAINT BEFORE THE CORPORATION SHALL NOT BAR A 
SEPARATE INDEPENDENT CRIMINAL ACTION BEFORE ANY 
COURT AGAINST THE ERRING HEALTH CARE PROVIDER OR 
MEMBER. AND VICE VERSA. 
SEC. 49-C. EXECUTION OF PENALTY - WHEN AN 
INSTITUTIONAL 
HEALTH 
CARE 
PROVIDER 
CEASES 
OPERATION 
OR 
AN 
INDEPENDENT 
HEALTH 
CARE 
PROFESSIONAL STOPS HIS/HER PRACTICE BEFORE SERVING 
THE SUSPENSION, EiXECUTION OF PENALTY SHALL BE 
DEFERRED, TO BE IMPLEMENTED WHEN THE SAME OWNER 
OR MEDICAL DIRECTOR OPENS OR OPERATES A NEW 
INSTITUTION IRRESPECTIVE OF THE NAME OR LOCATION, OR 
WHEN THE HEALTH CARE PROVIDER PRACTICES AGAIN. 
PROVIDED, 
THAT 
THE 
DISPOSITIVE 
PART 
OF 
THE 
RESOLUTION 
REQUIRING 
PAYMENT 
OF 
FINES, 
REIMBURSEMENT OF PAID CLAIM OR DENIAL OF PAYMENT 
SHALL BE IMMEDIATELY EXECUTORY. 
A SPOUSE OR RELATIVE WITHIN THE SECOND DEGREE 
OF CONSANGUINITY OR AFFINITY OF THE OWNER OR 
MEDICAL DIRECTOR SHALL BE PRESUMED TO BE THE ALTER 
EGO OF SUCH OWNER OR MEDICAL DIRECTOR FOR THE 
ABOVE PURPOSES. 
DESPITE THE CICSSATION OF OPERATION OR PRACTICE 
OF A HEALTH CARE PROVIDER WHILE THE COMPLAINT IS 
BEING HEARD, THE PROCEEDING SHALL CONTINUE UNTIL 
RENDITION OF JUDGMENT FOR PURPOSES OF DETERMINING 
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FUTURE RELATIONSHIPS BETWEEN THE CORPORATION AND 
THE ERRING HEALTH CARE PROVIDER. 
SEC. 49-D. APPLICABILITY OF THESE PROVISIONS - 
COMPLAINTS 
ALREADY 
FILED 
WITH 
AND 
UNDER 
DELIBERATION 
BY 
APPROPRIATE 
BODIES 
OF 
THE 
CORPORATION PRIOR TO THE EFFECTIVITY OF THIS ACT 
SHALL BE GOVERNED IN ACCORDANCE WITH THE PREVIOUS 
ACTS AND THEIR IMPLEMENTING RULES AND REGULATIONS. 
SEC. 49-E. VISITORIAL POWERS - THE CORPORATION 
SHALL BE VESTED WITH THE FOLLOWING AUTHORITY: 
A. 
TO VISIT, ENTER AND INSPECT HEALTH CARE 
PROVIDERS FACILITIES AND TO OBTAIN / SECURE 
THEIR 
MEDICAL, 
FINANCIAL 
AND 
OTHER 
NECESSARY AND / OR PERTINENT RECORDS AND 
THAT OF THEIR PATIENTS WHO ARE MEMBERS OR 
BENEFICIARIES OF THE PROGRAM; AND, 
B. 
TO 
VISIT, 
ENTER 
AND 
INSPECT 
THE 
ESTABLISHMENTS 
OF 
EMPLOYERS 
AND 
TO 
OBTAIN 
I 
SECURE 
NECESSARY 
AND 
/ 
OR 
PERTINENT RECORDS OF THEIR EMPLOYEES / 
PERSONNEL. 
SEC. 
49-F. 
IMPOSITION 
OF 
INTEREST 
AND 
SURCHARGES - THE CORPORATION MAY IMPOSE INTEREST 
AND SURCHARGES OF THREE PERCENT (3%) PER MONTH OR 
AT ANY RATE AS MAY BE FIXED BY THE CORPORATION IN 
CASE 
OF 
ANY 
DELAY 
IN 
THE 
REMITTANCE 
OF 
CONTRIBUTIONS WHICH ARE DUE WITHIN THE PRESCRIBED 
PERIOD. NOTHWITHSTANDING THE PROVISION OF ANY LAW 
TO 
THE 
CONTRARY, 
THE 
CORPORATION 
MAY 
ALSO 
COMPROMISE, WAIVE AND / OR RELEASE, IN WHOLE OR IN 
PART, SUCH INTEREST OR SURCHARGES UNDER SUCH TERMS 
AND CONDITIONS AS IT MAY PRESCRIBED. 
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SEC. 49-G. OTHER VIOLATIONS - All other violations 
[involving funds] of the PROVISIONS OF THIS ACT OR OF THE 
RULES AND REGULATIONS PROMULGATED BY THE Corporation 
shall be PUNISHED BY A FINE OF NOT LESS THAN FIVE 
THOUSAND PESOS (P5,OOO) NOR MORE THAN TWENTY 
THOUSAND PESOS (P20,000), OR IMPRISONMENT FOR NOT 
LESS THAN SIX (6) YEARS AND ONE (1) DAY BUT NOT TO 
EXCEED TWELVE (12) YEARS OR BOTH, AT THE DISCRETION 
OF THE COURT.[governed by the applicable provisions of the Revised 
Penal Code or other laws, taking into consideration the rules on 
collection, remittances, and investment of funds as may be 
promulgated by the Corporation.] 
SECTION 3. Implementing Rules & Regulations - The Philippine 
Health Insurance Corporation (PhilHealth) shall issue the necessary rules 
and regulations to implement the provisions of this Act. 
SECTION 4. Repealing Clause - All laws, issuances or any part 
thereof inconsistent with this Act are hereby repealed or modified 
accordingly. 
SECTION 5. Effectivity - This Act shall take effect fifteen (15) days 
after its complete publication in the Official Gazette or in at least two (2) 
national newspapers of general circulation. 
Approved, 
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