Life and health are constantly exposed to various dangers. Availability medical insurance- the opportunity to receive the necessary qualified assistance in a timely manner.

In the case of paid treatment, insurance allows you to fully or partially compensate for material costs.

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If medical services are free, then the insurance policy will allow you to finance an additional set of medical procedures and ensure high-quality rehabilitation.

Features of the activity of medical insurance structures

Modern insurance structures provide two types medical services:

• obligatory (state) insurance policy;
• voluntary agreement.

Compulsory health insurance() - the obligation of the state within the framework of existing social programs. The activities of the MHI are aimed at equalizing opportunities for access to healthcare facilities for all citizens of the country.

Voluntary medical insurance (VHI) is determined solely by the desire of citizens or employers and allows them to determine the list of necessary medical and other services in addition to those that are guaranteed state fund OMS. Voluntary medical insurance is concluded, both collective and personal.

Comparative table of CHI and VHI

MHI (compulsory health insurance)	VHI (voluntary medical insurance)
Mandatory part of the program of the state social package.	Voluntary action at the personal request of a private person (individual policy) or employer (collective document).
The CHI policy guarantees a minimum amount of free medical care, medicines and related materials.	Allows to provide a wide range of additional services (customer chooses) in addition to those guaranteed by the CHI.
Insurance is free of charge and is provided at the expense of taxpayers.	The client pays the policy according to the contract.
List of medical institutions providing medical care in within the CHI, is determined by a special territorial program of state guarantees.	Insurance Company independently develops voluntary medical insurance programs and attracts to cooperation medical organizations who will provide qualified assistance to their clients.

Rights individuals and the rules for their participation in the structure health insurance governs the law. Stateless persons of the Russian Federation have the same rights when applying for medical insurance as citizens of the country.

Insured events must be clearly stated in the contract, rules and conditions for the provision of the policy. The indemnity is paid on the condition that the situation corresponds to the insured event specified in the contract.

Rights of insurance companies

CMO has a large set of powers and rights in terms of registration of VHI. This type of insurance is currently regulated exclusively by general insurance laws.

Thus, they have the following rights:

• Choose any medical organization who will provide quality services to their customers;
• Conclude contracts with any medical and other specialized organizations for the provision of medical, rehabilitation and health procedures;
• Determine the amount of contributions;
• Independently negotiate prices for a list of services provided by medical institutions;
• Control the number of services, compliance with deadlines, the quality of therapeutic actions, represent and defend the interests of clients;
• Litigation against medical institutions, their employees, if they are guilty of causing physical, moral or material damage to the client;
• Return a share of the sum insured, if this possibility is provided for by the agreement (it is worth noting that such actions lead to the loss of tax benefits).

Responsibilities of health insurance companies

The main responsibility of the MCO– conscientiously fulfill all the clauses of the concluded agreements and ensure the high-quality fulfillment of their obligations by medical institutions.

An insurance company must ensure its solvency (financial reliability) by having a paid authorized capital and required material reserves. They are also required to strictly comply with all regulatory relationships between existing assets and material liabilities.

Employees of insurance structures are obliged to provide comprehensive support to customers if they encounter problems in obtaining medical care. For example:

• there were difficulties when making an appointment with a specialized specialist, or during an examination;
• there are comments about the examination and the treatment process, the quality of services;
• unreasonable demand for payment for examinations, medical care, medicines and materials.

In insurance companies dealing with medical policies, there are special groups for the highly professional protection of the rights of customers.

Qualified specialists refuse social, legal, economic support, participate in medical and economic examinations and examinations to determine the quality of services, contribute to judicial and judicial compensation for payment for treatment, compensation for harm caused to health by the actions of doctors.

Responsibility

All insurance undertakings are legally responsible to the insurance supervisory authority in terms of:

• validity of insurance rates;
• financial reliability;
• strict observance of all norms of the legislation of the Russian Federation.

Conflicts that have arisen between clients and insurers are resolved in court.

Types of medical insurance organizations

The main participants in the health insurance system of citizens include:

• insurers (organizations providing insurance services);
• insured citizens (clients);
• insurance medical organizations (SMOs);
• various medical structures.

The first two groups have the same composition, legal obligations and level of responsibility as other representatives of the insurance business. The last two subjects, according to the law "On Compulsory Medical Insurance in the Russian Federation", are subject to special requirements.

HMOs deal with only one type of insurance and are not entitled to other types of activities. HMOs are not an integral part of the healthcare system, medical institutions cannot be founders of HMOs or participate in management.

Insurance organizations Those who have the right (license) to work under the voluntary medical insurance program may specialize only in life and health insurance or provide other types of services. Those. Any organization that specializes in the provision of insurance services and has a license for medical insurance can become a subject of VHI.

Voluntary medical insurance is carried out in the legal field of the Law "On Insurance". It should be borne in mind that individual items of insurance documents from different insurers can significantly change. Therefore, if you want to issue a VHI policy, you should take a responsible attitude to the choice of an insurance company.

Clients are offered a wide range of diverse insurance programs. You can choose what is most relevant for a particular person. For example, insurance in case of disability (temporary / permanent), payment for rehabilitation activities, necessary sports and recreational activities, etc.

Criteria for choosing an insured

The main criteria to consider when choosing an insurance company:

• simplicity and execution of a package of documents;
• the reputation of the insurance company;
• quality of service;
• timeliness of compensation payments;
• the level of insurance premiums;
• the level of the insurance policy;
• degree of coverage of diseases (list of insured events).

When drawing up a package of documents for VHI, there is another important criterion - medical assistance.

Assistance ("assistance" - help) is a set of organizational services that facilitates the receipt by the company's clients of the support (assistance) specified by the contract.

Assistance is an intermediary between the insurer and medical institutions. Insurance organizations working with medical insurance use two types of assistance:

• internal, included in the structure of this company;
• external (an independent enterprise with which policyholders enter into service contracts).

Insurance companies that work with VHI, as a rule, interact with medical institutions (assisting enterprises). This approach provides conditions for the provision of professional medical assistance if the insured event occurred outside the territory of the insurance, i.e. in any region of the country and even beyond its borders.

Health insurance is important for the development of the healthcare system, allows you to provide diverse medical procedures, creates conditions for maximum quality treatment citizens.

An agreement is concluded between the HMO and a medical institution for the provision of preventive care (medical services) under compulsory medical insurance, the standard form of which is approved by the director of the MHIF in agreement with the head of the Federal Service for Supervision of Insurance Activities, and is an annex to the Model Rules for Compulsory Medical Insurance.

In accordance with the contract, the medical institution undertakes to provide medical and preventive care in accordance with the territorial CHI program and the types of activities permitted to it, the list of which is an integral part of the contract.

The important terms of the contract are as follows:

the medical institution is obliged to inform the insured about the free medical care provided to them under this contract;

if it is impossible to provide medical care of the agreed type, volume and/or standard, the medical institution is obliged to provide the insured with such assistance at its own expense in another institution or by engaging an appropriate specialist, informing the insurer about this.

The insurer undertakes to pay for medical care provided to citizens to whom they have issued insurance policies at the established rates in accordance with the procedure for paying for medical care in force in the territory. CHI system.

The insurer controls, through inspections, the compliance of the care provided by the medical institution with the requirements of the contract, approved standards for the quality of medical care (patient management protocols).

As a medical institution, i.e. The producer of medical services in the compulsory health insurance system can be not only medical institutions, but also research, medical institutes, other institutions providing medical care, as well as persons engaged in medical activities, both individually and collectively (Article 2 of the Law).

In case of violation of the terms of the contract by the insurer (untimely and / or incomplete financing) or by the health care facility (providing), economic sanctions are provided.

Violations by medical institutions may be of the following nature:

provision of medical care of inadequate volume and quality, confirmed by expert examination certificates;

violation of the legally established rights of citizens (patients);

program violation state guarantees providing citizens with free medical care;

invoices (registry invoices) not submitted on time for payment to the insurer;

improper registration of invoices (invoices-registries);

attempt to terminate the Agreement without following the appropriate procedure;

violation of the procedure for the use of CHI funds (misuse and / or irrational use of funds).

Legal basis for the development and approval of tgg

In the context of political and economic reforms in the country, the old methods of managing health care turned out to be unacceptable. During the first half of the 90s of the last century, according to a number of authors, the effectiveness of healthcare management was extremely low. This led to a departure from the uniform principles of planning, failure to implement the provisions of federal policy in the regions, significant inter-territorial differentiation in the availability and quality of certain types of medical care associated with disproportions in its planning and financing.

The need to restore the healthcare management system based on modern principles is reflected in the "Concept for the Development of Healthcare and Medical Science", approved by the Decree of the Government of the Russian Federation of 05.11.1997. (hereinafter referred to as the Concept). One of the first documents aimed at implementing the provisions of the Concept was the Program of State Guarantees for Providing Citizens of the Russian Federation with Free Medical Care, approved by the Decree of the Government of the Russian Federation of 11.09.1998. No. 1096. In accordance with it, the restoration of industry management should be carried out on the basis of uniform planning principles. By this Decree of the Government of the Russian Federation, it is recommended that the executive authorities of the constituent entities of the Russian Federation approve the TPGT. Thus, since 1998 medical care financed from the budgets of various levels and the funds of compulsory medical insurance, in the Russian Federation is provided within the framework of the PGGP and TPPG.

Registration N 23953

In accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in Russian Federation"(Collected Legislation of the Russian Federation, 2010, N 49, Art. 6422; 2011, N 25, Art. 3529; N 49, Art. 7047, Art. 7057) I order:

Approve:

Regulations on control over the activities of insurance medical organizations in the field of compulsory medical insurance territorial funds compulsory health insurance (Annex 1);

Regulations on control over the use of compulsory medical insurance funds by medical organizations (Appendix 2).

Chairman A. Yurin

Annex 1

Regulations on the control over the activities of insurance medical organizations in the field of compulsory medical insurance by territorial funds of compulsory medical insurance

I. General provisions

1. This Regulation has been developed in accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation" (Sobraniye Zakonodatelstva Rossiyskoy Federatsii, 2010, N 49, Art. 6422; 2011, N 25, Art. 3529 , N 49, art. 7047, 7057) (hereinafter - Federal Law N 326-FZ) for the purpose of regulatory and methodological support for the activities of territorial compulsory medical insurance funds (hereinafter - territorial funds) to monitor the activities of insurance medical organizations in the field of compulsory medical insurance, including control over the use of compulsory medical insurance funds by medical insurance organizations, through inspections and audits (hereinafter referred to as inspections).

II. Organization of the check

2. The territorial fund conducts inspections of insurance medical organizations (branches of insurance medical organizations) that carry out (carried out) activities in the field of compulsory medical insurance on the basis of an agreement concluded between the territorial fund and an insurance medical organization (branch of an insurance medical organization) (hereinafter referred to as insurance medical organizations ).

3. Inspections are carried out by employees of the control and audit divisions of the territorial fund and (or) other structural divisions of the territorial fund in order to prevent and detect violations of the norms established by Federal Law N 326-FZ, other federal laws and other regulatory legal acts of the Russian Federation adopted in accordance with them. Federation, laws and other regulatory legal acts of the constituent entities of the Russian Federation.

4. Checks are carried out at the location of the medical insurance organization (or at the place of actual implementation of its activities), including:

a comprehensive audit, which considers a set of issues related to compliance with the legislation on compulsory medical insurance and the use of compulsory medical insurance funds for a certain period of activity of an insurance medical organization;

a thematic audit, which considers certain issues related to compliance with the legislation on compulsory health insurance and (or) the use of compulsory health insurance funds;

control audit, which considers the results of the work of the insurance medical organization to eliminate violations and shortcomings previously identified in the course of a comprehensive or thematic audit.

The frequency of scheduled inspections is established taking into account the possibility of full coverage of issues and periods of activity of insurance medical organizations in the field of compulsory medical insurance, but not less than 1 (one) time per year. The frequency of scheduled comprehensive inspections is established no more than 1 (one) time per year.

The Territorial Fund may conduct unscheduled inspections. Unscheduled inspections are carried out by decision of the director of the territorial fund on the basis of submissions from control bodies, appeals to the territorial fund of state authorities of a constituent entity of the Russian Federation, Federal Fund compulsory medical insurance (hereinafter - the Federal Fund), appeals, complaints and applications of citizens, in connection with the expiration of the term for the fulfillment by the insurance medical organization of the requirements of the territorial fund to eliminate violations and shortcomings, and (or) return (reimbursement) of funds, and (or) payment fines (penalties), the conduct by the Federal Fund of inspections of compliance with the legislation on compulsory medical insurance in the territory of the constituent entity of the Russian Federation and the use of compulsory medical insurance funds by participants in compulsory medical insurance, in the event of termination of the agreement on the financial provision of compulsory medical insurance, including in connection with the suspension or termination of the license, liquidation of the insurance medical organization, in connection with the appeal of the insurance medical organization to the territorial fund with an application for the provision of missing funds to pay for medical care under territorial program compulsory medical insurance and other necessary cases.

An order to conduct a scheduled inspection is communicated to the head of the medical insurance organization no later than 3 (three) working days before the start of the inspection. An unscheduled inspection may be carried out without observing the condition of mandatory notification of the head of the medical insurance organization about the upcoming inspection.

The numerical and personal composition of the commission (working group) (from among the employees of the territorial fund) and the period of the audit are established taking into account the topic of the audit, the specifics of the activity of the medical insurance organization (including the number of insured persons by the insurance medical organization included in regional segment unified register insured persons, the number of points of issuance of compulsory health insurance policies, the number of medical organizations that have concluded an agreement with an insurance medical organization for the provision and payment of medical care under compulsory medical insurance), the duration of the period under review and the method of verification.

When conducting an audit of the activities of an insurance medical organization on issues related to the processing of personal data, the commission (working group) should include employees of the territorial fund with access to personal data.

The term of the audit may not exceed 30 (thirty) calendar days. If necessary, upon a reasoned submission in the form of a memorandum of the head of the control and audit unit of the territorial fund (the head of another unit of the territorial fund responsible for organizing a specific audit) or the head of the commission (working group), the period for conducting the audit may be extended based on the order of the territorial fund, but not more than 10 (ten) calendar days. The order of the territorial fund to extend the terms of the inspection is brought to the attention of the inspected medical insurance organization.

7. To conduct an audit, an audit program is drawn up or a standard audit program is used, which are approved by the director of the territorial fund.

the name of the insurance medical organization whose activities are subject to verification (when approving a standard verification program, the name of the insurance medical organization is not indicated);

the purpose of the check;

topic of the inspection (for scheduled inspections - the topic is indicated in accordance with the inspection plan; for unscheduled inspections - the theme is indicated based on the specific reasons for its conduct);

a list of issues related to the activity of an insurance medical organization subject to verification.

When compiling an audit program, a list of issues related to the activities of medical insurance organizations in the field of compulsory medical insurance, reflected in paragraphs 15 - 20 of this Regulation, can be used.

8. Before the start of the audit, the head and members of the commission (working group) must familiarize themselves with the contracts concluded between the territorial fund and the medical insurance organization being audited, the reporting and statistical data available in the territorial fund, the data on the number of insured persons by the medical insurance organization in the constituent entity of the Russian Federation and the dynamics of its change, with information from the territorial fund sent to the insurance medical organization, on the exclusion of insured persons from the register of this insurance medical organization for justified reasons, with acts of previous inspections carried out by the territorial fund, acts of inspections of control bodies, information on the elimination of identified violations and shortcomings and other materials related to the activities of the audited medical insurance organization.

If necessary, the audit program may include questions based on the materials of previous audits conducted by the territorial fund and (or) regulatory authorities, analysis of the reports of the insurance medical organization, data on the number of insured persons by the insurance medical organization in the constituent entity of the Russian Federation and the dynamics of its change, as well as other documents relating to the activities of the inspected medical insurance organization in the field of compulsory medical insurance.

9. Verification of the activities of an insurance medical organization can be carried out in a continuous or selective way.

III. Powers of the commission (working group) when conducting an audit of an insurance medical organization

request and receive from the officials of the insurance medical organization the documents, explanations, information and their certified copies necessary for the audit;

conduct inspections of branches of the insurance medical organization, points of issue of compulsory medical insurance policies and medical organizations that have received compulsory medical insurance funds from the audited medical insurance organization;

get access to information systems insurance medical organization, designed to fulfill the obligations of the insurance medical organization in the field of compulsory medical insurance (including those located at the points of issue of compulsory medical insurance policies), in the mode of viewing and selecting the necessary information, as well as receiving copies of documents (including electronic ones) and copies of other records (in the presence of employees of the insurance medical organization).

13. On the day the audit begins, the head, members of the commission (working group) present to the head of the insurance medical organization (the person replacing him) (in the case of an audit of the activities of the branch of the insurance medical organization - the head of the branch of the insurance medical organization (the person replacing him) a copy of the order territorial fund on the inspection, service certificates.

14. The head of the insurance medical organization (the person replacing him) (in the event of an audit of the activities of the branch of the insurance medical organization - the head of the branch of the insurance medical organization (the person replacing him) represents the head and members of the commission (working group) to the heads of structural divisions of the insurance medical organization and appoints a responsible person who coordinates the work of the structural units of the medical insurance organization during the audit of the medical insurance organization.

The head of the insurance medical organization (the person replacing him) (in the event of an audit of the activities of the branch of the insurance medical organization - the head of the branch of the insurance medical organization (the person replacing him) is obliged to provide the head and (or) members of the commission (working group) with the opportunity to familiarize themselves with the documents, related to verification issues.

15. The main issues of the activities of insurance medical organizations in the field of compulsory medical insurance are subject to verification:

organization and conduct of compulsory medical insurance (paragraph 16 of these Regulations);

organization and control of volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance (paragraph 17 of this Regulation);

protection of the rights and legitimate interests of the insured persons, consideration of appeals and complaints of the insured persons (paragraph 18 of this Regulation);

compliance with the requirements for the placement of information by insurance medical organizations (paragraph 19 of this Regulation);

observance by the insurance medical organization of the procedure for implementing the measures of the regional program for the modernization of healthcare of the constituent entity of the Russian Federation to introduce standards of medical care, increase the availability of outpatient medical care, including that provided by specialist doctors (including measures to conduct in-depth medical examinations of adolescents) (paragraph 20 of this Regulation).

16. Checking the organization and conduct of compulsory medical insurance in insurance medical organizations includes checking:

16.1. Constituent documents of the insurance medical organization, changes and additions to them.

16.2. The power of attorney issued to the head of the branch of the insurance medical organization, its validity period (in the event of an audit of the activities of the branch of the insurance medical organization).

16.3. Licenses of an insurance medical organization for conducting compulsory medical insurance, dates of its issue federal agency executive power, exercising the functions of control and supervision in the field of insurance activities (the original or a duly certified copy is considered).

16.4. Compliance with the norms of part 3 of Article 14 of the Federal Law N 326-FZ by the insurance medical organization (the absence of other activities of the insurance medical organization, except for the activities of compulsory and voluntary medical insurance).

16.5. Compliance of documents of an insurance medical organization with the information contained in the register of insurance medical organizations operating in the field of compulsory medical insurance of a constituent entity of the Russian Federation.

16.6. Compliance with the procedure for issuing a compulsory medical insurance policy to an insured person (including at the points of issuing compulsory medical insurance policies) established by the Rules for Compulsory Medical Insurance approved by Order of the Ministry of Health and Social Development of the Russian Federation No. 158n dated February 28, 2011 (registered by the Ministry of Justice of the Russian Federation on March 03, 2011) .2011, registration N 19998) (as amended by the order of the Ministry of Health and Social Development of the Russian Federation of 10.08.2011 N 897н) (registered by the Ministry of Justice of the Russian Federation on 12.08.2011, registration N 21609) (as amended by the order of the Ministry of Health and Social Development of the Russian Federation dated 09/09/2011 N 1036n) (registered by the Ministry of Justice of the Russian Federation on 10/14/2011, registration N 22053) (hereinafter referred to as the Rules for Compulsory Medical Insurance), including the following checks:

applications for the choice (replacement) of an insurance medical organization;

power of attorney from the representative of the insured person;

compliance by the insurance medical organization with the requirements established by Chapter II of the Rules for Compulsory Medical Insurance, when applying for the choice (replacement) of the insurance medical organization by the insured person;

compliance with the procedure for issuing a policy of compulsory medical insurance (hereinafter referred to as the policy) or a temporary certificate to the insured person, established by Chapter IV of the Rules for Compulsory Medical Insurance;

the timeliness of issuance to the insured person or his representative of a temporary certificate confirming the execution of the policy and certifying the right to free provision of medical care to the insured person by medical organizations upon the occurrence of insured event;

compliance with the deadlines for the transfer of information about the insured person who submitted an application for the choice (replacement) of an insurance medical organization to the territorial fund and the deadlines for checking for the presence of the insured person current policy in the regional segment of the unified register of insured persons;

compliance with the requirements of the procedure for maintaining personalized records in the field of compulsory medical insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation dated January 25, 2011 N 29n "On approval of the Procedure for maintaining personalized records in the field of compulsory medical insurance" (registered by the Ministry of Justice of the Russian Federation on February 8, 2011, registration N 19742), including the presence of an order identifying employees of an insurance medical organization admitted to work with the regional segment of the unified register of insured persons, compliance with the deadlines for the transfer of data on insured persons and information about changes in these data to the territorial fund, the accuracy of the information entered insurance medical organization in the regional segment of the unified register of insured persons;

implementation of informing the insured persons about the terms of registration and issuance of policies in order to ensure the timely issuance of policies;

the timeliness of the issuance of the policy to the insured person (within the period established by paragraph 50 of the Rules of Compulsory Medical Insurance: not exceeding the validity period of the temporary certificate) and the reasons for non-compliance with the terms of issuance;

observance of the terms and procedure for informing citizens about the fact of insurance and the need to obtain a policy - for citizens whose information is received by an insurance medical organization from a territorial fund in accordance with Part 6 of Article 16 of Federal Law N 326-FZ;

information on the number of insured persons by an insurance medical organization in a constituent entity of the Russian Federation, the dynamics of its change;

availability of acts of reconciliation with the territorial fund of data on the number of insured persons on the first day of each month, the reliability of the indicated data on the number of insured persons;

reliability of data on the number of insured persons used by the insurance medical organization when drawing up applications for receiving funds from the territorial fund;

the collection and processing of data by a medical insurance organization of personalized accounting of information about insured persons and personalized accounting of information about medical care provided to insured persons, ensuring their safety and confidentiality, exchanging said information between participants in compulsory medical insurance in accordance with Federal Law N 326-FZ .

16.7. Checking the accounting of forms of temporary certificates and policies of compulsory medical insurance, as forms of strict accountability, including checking:

Availability analytical accounting for each type of strict reporting forms and their storage locations;

compliance with the requirements for ensuring the safety of forms of temporary certificates and compulsory medical insurance policies, as forms of strict accountability, including at the points of issue of compulsory medical insurance policies;

the presence of an order of an insurance medical organization, agreed with the territorial fund, on the creation of a commission for writing off and destroying policies and temporary certificates;

compliance with the deadlines for the inventory accounting policy insurance medical organization (during the audit, an inventory or a selective inventory of policies and forms of temporary certificates, including at the points of issue of compulsory medical insurance policies, may be carried out).

16.8. Verification of payment for medical care provided to insured persons, including verification of:

contracts for the provision and payment of medical care under compulsory medical insurance;

compliance by the insurance medical organization with the norm of part 1 of article 39 of the Federal Law N 326-FZ (conclusion of an agreement for the provision and payment of medical care under compulsory medical insurance with medical organizations included in the register of medical organizations operating in the field of compulsory medical insurance of a constituent entity of the Russian Federation (hereinafter - register of medical organizations);

compliance of the concluded contracts for the provision and payment of medical care under compulsory health insurance with the form of a standard contract for the provision and payment of medical care under compulsory health insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation of December 24, 2010 N 1184n (registered by the Ministry of Justice of the Russian Federation on 04.02. 2011, registration N 19714) (hereinafter - the Standard contract for the provision and payment of medical care under compulsory medical insurance);

the presence of refusals to conclude an agreement for the provision and payment of medical care under compulsory medical insurance with a medical organization included in the register of medical organizations;

settlement accounts of an insurance medical organization (including checking an agreement with a bank for settlement and cash services) and accounting Money compulsory medical insurance on accounts;

compliance with the requirement of separate accounting of operations for voluntary and compulsory medical insurance;

the availability of balances of compulsory medical insurance funds at the start and end dates of the audited period, as well as at the start date of the audit;

the availability of balances of funds from the formed reserves that were not used at the end of 2011, and the implementation of their return to the territorial fund;

timeliness of submission by the insurance medical organization to the territorial fund of applications for earmarked funds to advance payment for medical care and applications for targeted funds to pay bills for medical care provided;

the correctness of drawing up applications for receiving targeted funds for advancing payment for medical care and for receiving targeted funds for paying bills for medical care provided (taking into account advances to medical organizations that were not confirmed by registers of accounts for the previous month) and sending targeted funds to medical organizations, including in order to exclude the facts of overestimation of the amounts of funds in the application for receiving funds from the territorial fund and the facts of unreasonable receipt of funds for the specified application due to unreliable data on the number of insured persons by this insurance medical organization;

the correctness of the formation of target funds for paying for medical care at the expense of funds received from the territorial fund for the financial support of compulsory medical insurance, funds received from medical organizations as a result of applying sanctions to them for violations identified during the control of volumes, terms, quality and conditions of provision medical care in the field of compulsory medical insurance, funds received from legal entities or individuals that caused harm to the health of insured persons (verification of the formation of target funds is carried out on the basis of a check banking operations insurance medical organization);

the correctness of the formation own funds in the field of compulsory health insurance from the sources provided for by Federal Law N 326-FZ, in accordance with the requirements established by the Standard Agreement on Financial Security for Compulsory Medical Insurance (hereinafter referred to as the Standard Agreement on Financial Security);

availability of separate accounting of own funds and targeted funds for payment of medical care;

use of target funds received in the period under review and carry-over balances of target funds to pay for medical care (based on the regulations of Part 6 of Article 39 of Federal Law N 326-FZ and the conditions model agreement on financial support and the Standard contract for the provision and payment of medical care under compulsory health insurance, payment for medical care provided to the insured person is carried out on the basis of registers of accounts and invoices for medical care provided by the medical organization within the scope of medical care provided by the decision of the Development Commission of the territorial program on tariffs for paying for medical care, taking into account the results of monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance. Verification of the use of targeted funds is carried out by checking the banking operations of the medical insurance organization and registers of accounts and invoices for payment of medical care (taking into account the results of monitoring the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance);

compliance of the payment for medical care by the medical insurance organization with the cost of the medical care provided in the registers of accounts and invoices for payment for medical care provided by the medical organization (taking into account the results of monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance);

availability of claims for reimbursement of expenses for the provision of medical care due to harm to the health of the insured person (recourse claims) (except for cases of harm caused by a severe accident at work) if the insurance medical organization has information;

fulfillment by an insurance medical organization of the terms of contracts for the provision and payment of medical care under compulsory medical insurance in terms of meeting the deadlines for transferring funds to a medical organization;

validity of appeals of the insurance medical organization to the territorial fund for the provision of targeted funds in excess of the established amount of funds to pay for medical care for this insurance medical organization from the normalized safety stock territorial fund;

reliability of the report of the medical insurance organization on the use of targeted funds submitted to the territorial fund simultaneously with the application for the provision of targeted funds in excess of the established amount of funds for paying for medical care for this medical insurance organization from the normalized insurance reserve of the territorial fund;

the timeliness of the direction by the medical insurance organization of the received funds of the normalized insurance reserve of the territorial fund to pay for medical care provided to insured persons within the framework of the territorial program of compulsory medical insurance;

compliance of the data contained in the acts of reconciliation of settlements between the territorial fund and insurance medical organizations (reconciliation of settlements is carried out monthly), data accounting insurance medical organization;

timeliness of payment to medical organizations for medical care provided to insured persons, taking into account the results of monitoring the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance;

the presence of a debt of an insurance medical organization to medical organizations and the identification of its causes, the existence and validity of claims of medical organizations to an insurance medical organization;

availability of acts of reconciliation of settlements between the insurance medical organization and medical organizations (according to the Standard contract for the provision and payment of medical care under compulsory medical insurance, the reconciliation of settlements by the insurance medical organization and the medical organization is carried out monthly on the 1st day of the month following the reporting one, and also annually as of the end of the financial year, based on the results of which an act of acceptance for payment of the provided medical care is drawn up, confirming the amount of the final settlement between the parties);

timeliness and completeness of the return of the balance of target funds to the territorial fund after the completion of settlements with medical organizations for the reporting month;

compliance with the deadlines for the return (reimbursement) by the medical insurance organization of the funds of compulsory medical insurance used for other purposes to the budget of the territorial fund and the payment of penalties based on the results of inspections previously conducted by the territorial fund (if any);

compliance with the deadlines for notifying insured persons, medical organizations and the territorial fund of the intention to terminate the contract at the initiative of the insurance medical organization (in case of early termination agreements on financial provision of compulsory medical insurance);

compliance with the deadlines for the return of funds to the budget of the territorial fund upon termination of the agreement on financial support for compulsory medical insurance;

reliability and timeliness of submission to the territorial fund of reports on the activities of an insurance medical organization in the field of compulsory medical insurance and reports on the receipt and expenditure of compulsory medical insurance funds by insurance medical organizations.

16.9. Verification of the use of the funds of the financial support reserve for preventive measures of the medical insurance organization, formed in accordance with the agreement on financial support, including the following checks:

compliance with the conditions for the transfer of funds from the reserve for financial support of preventive measures to medical organizations;

timeliness and completeness of the return to the territorial fund of the balance of the reserve of financial support for preventive measures not used by the insurance medical organization.

17. Verification of the organization and conduct of control by the insurance medical organization of the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance includes verification of:

17.1. Compliance by the insurance medical organization with the rules and procedures for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance, established by order of the Federal Fund dated December 01, 2010 N 230 "On approval of the procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance" (registered by the Ministry of Justice of the Russian Federation on January 28, 2011, registration N 19614) (as amended by the order of the Federal Fund of August 16, 2011 N 144) (registered by the Ministry of Justice of the Russian Federation on December 9, 2011, registration N 22523) (hereinafter - the order of the Federal Fund N 230). Conducted medical and economic control, medical and economic examination, examination of the quality of medical care, including repeatedly. When checking, the facts of payment for medical care on invoices and registers of invoices with violations in their execution and presentation for payment by medical organizations are reflected in accordance with section 5 of the List of grounds for refusing to pay for medical care (reducing payment for medical care), which is Appendix 8 to the Order of Organization and monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance (hereinafter referred to as the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care), approved by order of the Federal Fund N 230, and for paying for medical care in case of collection of fees from insured persons (as part of voluntary medical insurance or in the form of providing paid services) for the medical care provided, provided for by the territorial program of compulsory medical insurance (clause 1.4. of the List of grounds for refusing to pay for medical care (reducing the payment for medical care), which is Appendix 8 to the Procedure for organizing and monitoring the volume, timing, quality and conditions for the provision of medical care ).

17.2. Compliance of the composition of medical care quality experts of the insurance medical organization with the requirements of the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care and the Procedure for maintaining the territorial register of medical care quality experts by the territorial fund of compulsory medical insurance and posting it on the official website of the territorial fund of compulsory medical insurance on the Internet, approved by Order of the Federal Fund of December 13, 2011 N 230 "On Approval of the Procedure for Maintaining the Territorial Register of Experts on the Quality of Medical Care by the Territorial Compulsory Medical Insurance Fund and Posting it on the Official Website of the Territorial Compulsory Medical Insurance Fund on the Internet" (registered The Ministry of Justice of the Russian Federation 01.02.2012, registration N 23086) (hereinafter referred to as the Procedure for Maintaining the Register of Experts), including checking the availability of documents necessary for inclusion of medical specialists in the territorial register of experts in the quality of medical care, provided for by the Procedure for maintaining the register of experts.

17.3. Carrying out expert work, including checking:

compliance with the deadlines for monitoring the volumes, terms, quality and conditions for the provision of medical care, established by the Order organizing and monitoring the volume, timing, quality and conditions of medical care;

fulfillment of the volumes of medical and economic control, medical and economic examination and examination of the quality of medical care established by the Procedure for organizing and conducting control over the volumes, terms, quality and conditions for the provision of medical care;

reliability and timeliness of reporting on the results of monitoring the volume, timing, quality and conditions of medical care.

When checking the expert work of an insurance medical organization, the following is reflected, among other things:

the presence of unjustified withdrawal of funds from medical organizations based on the results of monitoring the volumes, terms, quality and conditions for the provision of medical care in the implementation of compulsory medical insurance;

the presence of unidentified defects in the provision of medical care;

non-application of penalties to medical organizations based on the results of monitoring the volumes, terms, quality and conditions for the provision of medical care if there are grounds for their application;

the presence of claims from medical organizations based on the results of monitoring the volumes, terms, quality and conditions for the provision of medical care, carried out by an insurance medical organization.

18. Verification of the activities of the insurance medical organization for the protection of the rights and legitimate interests of the insured persons in the consideration of appeals and complaints of citizens (insured persons) includes verification of:

the procedure for servicing persons with disabilities, including the disabled;

work with citizens' appeals for compliance with the Federal Law of May 2, 2006 N 59-FZ "On the Procedure for Considering Appeals from Citizens of the Russian Federation" (Sobraniye Zakonodatelstva Rossiyskoy Federatsii, 2006, N 19, Art. 2060; 2010, N 27, Art. 3410; N 31, article 4196) and other regulatory legal acts regulating the work with citizens' appeals;

receiving, accounting (registration) of incoming appeals (complaints, applications) of insured persons, including the choice of a doctor and a medical organization, the volume and quality of medical care provided in medical organizations, etc.;

timeliness of consideration and validity of decisions made on appeals. When checking, the facts of violation of the terms of consideration of the appeals of the insured persons, failure to inform the applicant of the results of the consideration of appeals (complaints, applications) or examination of the quality of medical care are reflected;

completeness of consideration of the appeal (application, complaint);

accounting for scheduled and unscheduled examinations of the quality of medical care, incl. repeated with the disagreement of medical organizations;

the presence of refusals to conduct an examination of the quality of medical care on the complaint of the insured person and their reasons;

accounting for cases of pre-trial and judicial resolution contentious issues and conflict situations with the participation of an insurance medical organization that arise between medical organizations and patients;

availability of information on the consent of a citizen or his legal representative to the settlement of a conflict situation in a pre-trial procedure, offered by a medical organization or an insurance medical organization;

organization and conduct by the insurance medical organization of events aimed at studying the satisfaction of citizens with the quality of medical care provided;

availability in the insurance medical organization of analysis of the results of sociological surveys (questionnaires) on the satisfaction of the insured persons with the availability and quality of medical care;

the presence of an analysis of the work carried out by the insurance medical organization with the appeals of citizens and the measures taken to prevent the occurrence of complaints;

reliability and timeliness of submission of reports on the organization of protection of the rights of insured persons in the field of compulsory health insurance.

19. Verification of compliance with the requirements for the placement of information by insurance medical organizations includes verification of:

availability of its own official website of the insurance medical organization on the Internet. Compliance with the requirements for the placement of information by insurance medical organizations established by Chapter XIII of the Rules for Compulsory Medical Insurance. Compliance of the information posted on the official website of the medical insurance organization on the Internet with legislative and other regulatory legal acts;

ensuring that insured persons are informed about the types, quality and conditions of providing them with medical care by medical organizations, identified violations in the provision of medical care to them, the right to choose a medical organization, the need to apply for a compulsory medical insurance policy, as well as the obligations of insured persons in accordance with the Federal Law N 326-F3; availability of information stands (posters) at points of issue of compulsory health insurance policies;

ensuring the provision of information to the insured persons who asked the question, including by e-mail or on the official website on the information and communication network "Internet" in the "question-answer" mode.

20. Checking the issue of compliance by the medical insurance organization with the procedure for implementing the measures of the regional program for the modernization of health care of the constituent entity of the Russian Federation (hereinafter referred to as the Modernization Program) for the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by medical specialists (including measures for conducting in-depth medical examinations adolescents), includes checking:

additional agreements to contracts for the provision and payment of medical care under compulsory medical insurance (these additional agreements must be concluded with medical organizations included in the list of medical organizations that are paid for medical care under the Modernization Program);

compliance with the procedure for the formation and submission to the territorial fund of applications for funds for the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors, established by order of the Federal Fund dated February 22, 2011 N 40 "On approval of the procedure for the formation and application form to receive funds for the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by medical specialists" (registered by the Ministry of Justice of the Russian Federation on 04/01/2011, registration N 20370);

payment for medical care provided under the Modernization Program at the expense of the budget of the Federal Fund (compliance when paying for medical care under the Modernization Program of the established additional tariffs and payment terms). Verification of the use of funds for these purposes is carried out on the basis of bank documents of the insurance medical organization and registers of accounts and invoices for payment of medical care under the Modernization Program at the expense of the budget of the Federal Fund;

compliance with the payment for medical care made by the medical insurance organization under the Modernization Program at the expense of the budget of the Federal Fund for the Cost of Provided Medical Care in the registers of accounts submitted by the medical organization and the invoice for payment for medical care under the Modernization Program at the expense of the budget of the Federal Fund;

compliance by the medical insurance organization with the procedure for determining from the total amount of funds received from the territorial fund according to differentiated per capita standards, the amount of funds allocated to pay for medical care under the Modernization Program at the expense of the budget of the territorial fund, as well as the budget of the constituent entity of the Russian Federation (if these funds are provided as financial support for the territorial program of compulsory medical insurance and are transferred to the budget of the territorial fund in the form of interbudgetary transfers);

payment for medical care provided under the Modernization Program at the expense of the budget of the territorial fund and the budget of the constituent entity of the Russian Federation (if such funds are provided), compliance by the medical insurance organization when paying for medical care provided under the Modernization Program at the expense of the budget of the territorial fund and the budget of the constituent entity of the Russian Federation, the procedure for implementing the Modernization Program and spending funds for the Modernization Program, approved in the territory of the constituent entity of the Russian Federation;

fulfillment by the insurance medical organization of the obligation to allocate in the total amount of funds allocated to medical organizations to pay for medical care under the territorial program of compulsory medical insurance, including the amount of funds allocated under the Modernization Program at the expense of the budget of the territorial fund, as well as the budget of the subject the Russian Federation (if the specified funds are provided);

carrying out by the insurance medical organization of control of volumes, terms, quality and conditions of rendering medical care within the framework of the Modernization Program; fulfillment by the insurance medical organization of the obligation to reflect in the acts of control of the volumes, terms, quality and conditions for the provision of medical care under the Modernization Program, funds that are not payable under the Modernization Program;

fulfillment by the insurance medical organization of the obligation to separately reflect in the accounting records the receipts and expenditures of funds under the Modernization Program by sources with the maintenance of analytical accounting on sub-accounts;

fulfillment by the insurance medical organization of the obligation to return to the territorial fund the funds of the budget of the Federal Fund that were not spent for the purposes specified in the application for their receipt (in the event that the balance of these funds is formed as a result of the termination or suspension of the activities of the insurance medical organization);

the presence in the insurance medical organization of reports of medical organizations on the use of funds for the purposes of implementing the regional healthcare modernization program;

formation and reliability of reports of the insurance medical organization on the use of funds for the purposes of implementing the Modernization Program;

execution by the insurance medical organization of the decisions adopted by the working group on the analysis of the implementation of the Modernization Program created in the constituent entity of the Russian Federation.

V. Registration of the act of verification

21. Based on the results of the audit, an audit report is drawn up, including:

21.1. The heading, which indicates the name of the subject of the check, the full name of the insurance medical organization (branch of the insurance medical organization) and the date of drawing up the act.

period under review;

surnames, initials of the head of the insurance medical organization (branch of the insurance medical organization), deputy head of the insurance medical organization (branch of the insurance medical organization), chief accountant and other officials of the insurance medical organization (branch of the insurance medical organization), who during the audited period had the right of the first ( second) signature. If there are changes in the audited period in the composition of the above-mentioned persons, their list is given with a simultaneous indication of the period during which these persons held the relevant positions in accordance with orders, orders for their appointment to a position and dismissal from their position;

list and details of all accounts of the medical insurance organization (branch of the medical insurance organization) (including accounts closed on the date of the audit, but active in the audited period) used by the audited medical insurance organization when carrying out activities in the field of compulsory medical insurance, opened in credit institutions, indicating the cash balances at the start and end dates of the audited period, as well as at the start date of the audit;

other data necessary for the full characterization of the insurance medical organization, including the act of inspection briefly reflects information on previous inspections of the activities of the insurance medical organization by control authorities, on the date and period checked by the previous inspection conducted by the territorial fund, on the elimination (non-elimination) of shortcomings and violations identified by the previous check, if they are not eliminated, the reasons are indicated;

information on the method of conducting the audit according to the degree of its coverage primary documents(continuous, selective) indicating which documentation was checked in a continuous and which selective way;

information on inspections of branches of the medical insurance organization, points of issue of compulsory medical insurance policies, medical organizations that received compulsory medical insurance funds from the audited medical insurance organization;

description of the audited issues of the activity of the medical insurance organization in accordance with the audit program (if necessary, based on the specific circumstances of the audit, the audit report may contain information on issues and periods of activity of the medical insurance organization that are not included in the audited period and the audit program).

The description of the facts of violations and deficiencies identified during the audit (including the facts of misuse of compulsory medical insurance funds and the facts of violation of contractual obligations for which the application of penalties) must contain mandatory information about specifically violated norms of legislative, other regulatory legal acts or their individual provisions, indicating the period for which violations were committed, when and in what way they expressed themselves, the amounts of documented non-target expenses and expenses incurred in violation of legislative and other regulatory legal acts.

In case of non-submission or incomplete submission by the insurance medical organization of documents for the inspection, a list of them is given in the inspection report.

21.3. The final part, which includes generalized information on the results of the audit, indicating the identified violations and shortcomings and the deadlines for their elimination or the deadlines for submitting an action plan to eliminate the identified violations and shortcomings.

When facts of violation of contractual obligations established by the agreement on financial support of compulsory medical insurance are revealed, including facts of misuse of compulsory medical insurance funds by an insurance medical organization, as well as facts of non-refund (non-reimbursement) and (or) untimely return (late compensation) by the insurance medical the organization of compulsory medical insurance funds used for other purposes, the budget of the territorial fund, the final part of the inspection report includes generalized information on the directions of violations of contractual obligations and the amounts of misuse of compulsory medical insurance funds with a demand for return (reimbursement) by an insurance medical organization (branch insurance medical organization) funds used for other purposes, and payment of a fine for the use of funds not for their intended purpose by an insurance medical organization of targeted funds, in accordance with parts 11, 12 of Article 38 of Federal Law N 326-FZ and (or) payment of fines, penalties for breach of contract.

In case of establishing the facts of non-return to the budget of the territorial fund of targeted funds not used by the insurance medical organization (branch of the insurance medical organization) for the intended purpose, remaining after the full fulfillment of its obligations under contracts for the provision and payment of medical care under compulsory medical insurance, and ( or) in the event of termination of the agreement on financial support of compulsory medical insurance, including in connection with the suspension or termination of a license, liquidation of an insurance medical organization, the final part of the inspection report shall include a requirement to return these funds to the budget of the territorial fund, as well as payment of penalties for untimely return to the budget of the territorial fund of funds upon termination of the contract on financial support for compulsory health insurance within ten working days from the date of termination of the contract.

21.4. The certification part, including the names, initials, positions and signatures of the head and members of the commission (working group) who conducted the audit of the activities of the medical insurance organization, the names, initials, positions and signatures of officials of the verified medical insurance organization:

when checking the activities of insurance medical organizations ( legal entities) - the audit report is signed by the head and members of the commission (working group), the head of the medical insurance organization (the person replacing him) and the chief accountant of the medical insurance organization;

when checking the activities of branches of insurance medical organizations - the act of checking is signed by the head and members of the commission (working group); the head of the branch of the insurance medical organization (the person replacing him) and the chief accountant of the branch of the insurance medical organization.

22. The act of verification is drawn up in two copies, having the same force. The head of the insurance medical organization (the person replacing him) (in the event of an audit of the activities of the branch of the insurance medical organization - the head of the branch of the insurance medical organization (the person replacing him) shall submit the inspection report in two copies for review and signing no later than 1 (one) the day before the end of the inspection period, determined by the order of the territorial fund on the inspection.

One copy of the signed act of inspection is handed over to the head of the insurance medical organization (the person replacing him) (in the event of an inspection of the activities of the branch of the insurance medical organization - to the head of the branch of the insurance medical organization (the person replacing him), the second copy is submitted to the territorial fund.

In a copy of the act of inspection, which is submitted to the territorial fund, a record is made of the receipt of one copy of the act of inspection by the head of the insurance medical organization (the person replacing him). Such a record must contain, among other things, the date of receipt of the verification report, the signature of the person who received the verification report, and the transcript of this signature.

The date of receipt of the act by the head of the insurance medical organization (the person replacing him) is considered the date of completion of the audit.

In case of refusal of the head of the insurance medical organization (the person replacing him) to sign and (or) receive the inspection report by the head of the commission (working group), at the end of the inspection report, an entry is made about the refusal to sign the inspection report or about the refusal to sign in receiving the verification report.

In the event that the head of the insurance medical organization (the person replacing him) (the head of the branch of the insurance medical organization (the person replacing him) refuses to sign and receive the audit report, the date of completion of the audit and the date of receipt of the audit report is considered the sixth business day from the date the audit report was sent to the address of the insurance medical organization (branch of an insurance medical organization) by registered mail with acknowledgment of receipt.

A document confirming the fact that an inspection report has been sent to an insurance medical organization shall be attached to the inspection materials.

In case of disagreement with the audit report (or its individual provisions), the head of the insurance medical organization (the person replacing him) signing it (the head of the branch of the insurance medical organization (the person replacing him) makes a note that the act is signed with objections that are attached to the audit report or are sent to the territorial fund no later than 5 (five) working days from the date of receipt of the inspection report Written objections of the insurance medical organization to the inspection report are attached to the inspection materials.

In the event that the officials of the insurance medical organization (branch of the insurance medical organization) refuse to sign the inspection report or receive the inspection report and (or) fail to submit written objections to the inspection report, the end date of the inspection is considered the sixth business day from the date of dispatch of the insurance medical organization (branch of the insurance medical organization) of the inspection report by registered mail with a return receipt.

23. When identifying violations and shortcomings, the following shall be attached to the inspection report:

tables of necessary calculations;

acts of inspections of branches of an insurance medical organization, points of issuance of compulsory medical insurance policies, medical organizations that received compulsory medical insurance funds from an inspected insurance medical organization;

other necessary materials.

All annexes drawn up during the audit must be signed by the head or a member of the commission (working group) and the head (a person replacing him) of the inspected medical insurance organization (in the case of an audit of the activities of a branch of an insurance medical organization - the head of a branch of an insurance medical organization (a person who replacing him) (with visas page by page).

Copies of documents confirming the violations identified during the audit, including violations in the use of compulsory medical insurance funds, are certified by the signature of the head of the medical insurance organization or the chief accountant of the medical insurance organization and the seal of the medical insurance organization. If necessary, it is allowed to compile a register of primary documents confirming violations, including violations in the use of compulsory medical insurance funds, which is signed by the head or member of the commission (working group) and the head of the medical insurance organization (the person replacing him) (in the event of an audit of the activities of the branch insurance medical organization - by the head of the branch of the insurance medical organization (a person replacing him) or the chief accountant of the insurance medical organization (branch of the insurance medical organization) (with visas page by page) and is certified by the seal of the insurance medical organization (branch of the insurance medical organization).

24. Not later than 10 (ten) working days after the end of the audit, the head of the commission (working group) submits to the director (deputy director) of the territorial fund a memo on the results of the audit of the activities of the insurance medical organization in the field of compulsory medical insurance.

25. If there are written objections to the inspection report, no later than 5 (five) working days from the date of their receipt, the territorial fund sends to the head of the insurance medical organization (head of the branch of the insurance medical organization) a written message on the results of consideration of objections to the inspection report, prepared by the structural unit of the territorial fund responsible for organizing a specific audit, signed by the director (deputy director) of the territorial fund, indicating the grounds on which objections are recognized as unfounded, or on the recognition of justified objections (partially justified objections) of an insurance medical organization.

If the objections are not recognized as justified or the objections of the insurance medical organization are partially recognized as justified, the written message shall include information that the terms for eliminating the violation and (or) the terms for the return (reimbursement) of funds, including those used for other purposes, and (or) payment fines, penalties are calculated from the date of presentation of the relevant requirement by the territorial fund.

A written message on the results of consideration of objections to the inspection report is handed over to the head of the medical insurance organization (branch of the insurance medical organization) or a person authorized by him, against receipt, or sent to the insurance medical organization (branch of the insurance medical organization) by registered mail with acknowledgment of receipt.

A copy of the written report of the territorial fund on the results of consideration of the objections of the insurance medical organization (branch of the insurance medical organization) to the inspection report and the document confirming the fact that the insurance medical organization (branch of the insurance medical organization) sent the specified written message are attached to the materials of the audit.

In case of disagreement with the result of consideration by the territorial fund of written objections to the inspection report, the medical insurance organization (branch of the insurance medical organization) has the right to appeal this decision in pre-trial and (or) judicial procedure.

26. The return (reimbursement) of funds, including those used for other purposes, and (or) the payment of fines, penalties, is carried out by an insurance medical organization (a branch of an insurance medical organization) on the basis of an inspection report in the manner prescribed by Federal Law N 326-FZ.

27. The Territorial Fund provides control over the implementation of the results of the audit, including the following:

control over the return (reimbursement) of funds, including those used for other purposes;

accrual of penalties and sending a written notice to the insurance medical organization about the need to pay penalties (with the calculation of the amount of penalties attached).

28. In accordance with Part 14 of Article 38 of Federal Law N 326-FZ, in the event of a violation of contractual obligations, the territorial fund, when reimbursement of the medical insurance organization for the costs of paying for medical care, has the right to reduce payments by the amount of the identified violations.

29. In the event that in the activities of the insurance medical organization (branch of the insurance medical organization) facts of violation of the legislation on compulsory medical insurance, requiring immediate measures to eliminate them, in the event of failure by the insurance medical organization (branch of the insurance medical organization) to fulfill the requirements of the territorial fund for the return (reimbursement ) funds, including those used for other purposes, and (or) on the payment of fines, penalties, and also in case of failure to eliminate the identified violations within the established time frame, the territorial fund has the right to send relevant information and verification materials to law enforcement and judicial authorities to attract the perpetrators to responsibility.

VII. Final provisions

30. Inspection plans, programs of scheduled and unscheduled inspections (standard inspection programs), inspection materials consisting of original copies of inspection certificates and properly executed annexes to them, to which references are given in inspection certificates, as well as documents provided for in Chapter VI of this Regulation, are completed, recorded and stored in the manner prescribed by the legislation on archiving in the Russian Federation and the rules of office work in the territorial fund.

Annex 2

Regulations on control over the use of compulsory medical insurance funds by medical organizations

I. General provisions

1. This Regulation has been developed in accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation" (Sobraniye Zakonodatelstva Rossiyskoy Federatsii, 2010, N 49, Art. 6422; 2011, N 25, Art. 3529 ; N 49, art. 7047, art. 7057) (hereinafter - Federal Law N 326-FZ) for the purpose of regulatory and methodological support for the activities of territorial compulsory medical insurance funds (hereinafter - territorial funds) to control the use of compulsory medical insurance funds by medical organizations through inspections and audits (hereinafter referred to as inspections).

II. Organization of the check

2. The Territorial Fund conducts inspections of medical organizations in the field of compulsory medical insurance (hereinafter referred to as medical organizations) that have the right to carry out medical activities and are included in the register of medical organizations operating in the field of compulsory medical insurance:

organizations of any organizational and legal form provided for by the legislation of the Russian Federation;

individual entrepreneurs engaged in private medical practice.

3. Inspections are carried out by employees of the control and audit divisions of the territorial fund and (or) other structural divisions of the territorial fund in order to prevent and detect violations of the norms established by Federal Law N 326-F3, other federal laws and other regulatory legal acts of the Russian Federation adopted in accordance with them. Federation, laws and other regulatory legal acts of the constituent entities of the Russian Federation.

4. Checks are carried out at the location of the medical organization (or at the place of actual implementation of its activities), including:

a comprehensive audit, which considers a set of issues related to the use of compulsory medical insurance funds for a certain period of activity of a medical organization;

thematic audit, which considers certain issues related to the use of compulsory health insurance funds;

a control audit, which considers the elimination of violations and shortcomings by a medical organization in the use of compulsory medical insurance funds previously identified during a comprehensive or thematic audit.

5. Inspections are carried out in accordance with the plan approved by the director of the territorial fund (scheduled inspections).

The frequency of scheduled inspections is established taking into account the possibility of full coverage of issues and periods of activity of medical organizations in the field of compulsory health insurance, but not less than 1 (once) every two years. The frequency of scheduled comprehensive inspections is established no more than 1 (one) time per year.

The Territorial Fund may conduct unscheduled inspections. Unscheduled inspections of the use of compulsory medical insurance funds are carried out by decision of the director of the territorial fund on the basis of submissions from control authorities, appeals to the territorial fund of state authorities of a constituent entity of the Russian Federation, the Federal Compulsory Medical Insurance Fund (hereinafter referred to as the Federal Fund), appeals, complaints and statements from citizens, due to the expiration of the term for the medical organization to fulfill the requirements of the territorial fund to eliminate violations and shortcomings, and (or) return (reimburse) funds, and (or) pay fines (penalties), the Federal Fund checks compliance with the legislation on compulsory medical insurance in the territory of the subject of the Russian Federation and the use of compulsory medical insurance funds by participants in compulsory medical insurance, in the event of termination of the contract for the provision and payment of medical care under compulsory medical insurance, including in connection with the suspension or termination of a license, liquidation of a medical organization and other necessary cases.

6. The basis for the audit is the order of the territorial fund, which determines the topic of the audit, the audited period, the head and composition of the commission (working group), the timing of the audit.

For scheduled checks, the subject of the check is indicated in accordance with the plan of checks, for unscheduled checks, the subject of the check is indicated based on the specific reasons for its conduct.

The order to conduct a scheduled inspection is communicated to the head of the medical organization no later than 3 (three) working days before the start of the inspection. An unscheduled inspection may be carried out without observing the condition of mandatory notification of the head of the medical organization about the upcoming inspection.

The numerical and personal composition of the commission (working group) (from among the employees of the territorial fund) and the period of the audit are established taking into account the topic of the audit, the characteristics of the activities of the medical organization, the duration of the audited period and the method of verification.

Depending on the topic of the audit, specialists from other control bodies may be included in the composition of the commission (working group) at the proposals of the control bodies.

When conducting an audit of the use of compulsory medical insurance funds by a medical organization related to the processing of personal data, the commission (working group) should include employees of the territorial fund with access to personal data.

The term of the audit may not exceed 30 (thirty) calendar days. If necessary, upon a reasoned submission in the form of a memorandum of the head of the control and audit unit of the territorial fund (the head of another unit of the territorial fund responsible for organizing a specific audit) or the head of the commission (working group), the period for conducting the audit may be extended based on the order of the territorial fund, but not more than 10 (ten) calendar days. The order of the territorial fund to extend the inspection period is brought to the attention of the medical organization being inspected.

7. To conduct an audit, an audit program is drawn up or a standard audit program (hereinafter referred to as the audit program) is used, which are approved by the director of the territorial fund.

The verification program must contain the following information:

the name of the medical organization that is subject to verification in terms of the use of compulsory medical insurance funds (when approving a standard verification program, the name of the medical organization is not indicated);

the purpose of the check;

topic of the audit (for scheduled audits - the topic is indicated in accordance with the audit plan; for unscheduled audits - the topic is indicated based on the specific reasons for its conduct);

list of questions to be checked.

When compiling the verification program, the list of issues reflected in paragraphs 15 - 22 of these Regulations can be used.

8. Before starting the audit, the head and members of the commission (working group) should familiarize themselves with the contracts concluded by the medical organization being audited with the territorial fund and (or) with insurance medical organizations operating in the field of compulsory medical insurance, reporting and statistical data available in the territorial fund, with acts of previous inspections conducted by the territorial fund, acts of inspections of control bodies, information on the elimination of identified violations and shortcomings, and other materials related to the use of compulsory medical insurance funds by the inspected medical organization.

If necessary, the audit program may include questions based on the materials of previous audits conducted by the territorial fund and (or) control bodies, analysis of the reports of the medical organization, as well as other documents related to the use of compulsory medical insurance funds by the audited medical organization.

9. Verification of the use of compulsory health insurance funds may be carried out in a continuous or selective manner.

A continuous method consists in carrying out a control action in relation to the entire set of financial, accounting, reporting and other documents related to one issue of the verification program.

The selective method consists in carrying out a control action in relation to a part of financial, accounting, reporting and other documents related to one issue of the verification program. The size of the sample and its composition are determined by the head of the commission (working group) in such a way as to ensure the possibility of assessing the issue under study of the verification program.

The decision to use a continuous or selective method of conducting control actions for each issue of the inspection program is made by the director (deputy director) of the territorial fund or the head of the structural unit of the territorial fund responsible for organizing the inspection, and (or) the head of the commission (working group) based on the content of the issue verification program, the volume of financial, accounting, reporting and other documents related to this issue, the state of accounting, the timing of the verification.

III. Powers of the commission (working group) when conducting an audit of a medical organization

10. The head and members of the commission (working group) have the right to:

request and receive from the officials of the medical organization the documents, explanations, information and their certified copies necessary for the inspection;

get access to the information systems of a medical organization designed to fulfill the obligations of a medical organization in the field of compulsory health insurance, in the mode of viewing and selecting the necessary information, as well as receive copies of documents (including electronic ones) and copies of other records (in the presence of employees of a medical organization) .

11. The head and members of the commission (working group) are obliged:

be guided by legislative and other regulatory legal acts;

objectively reflect in the documents the facts of violations and shortcomings revealed by the audit.

12. The head of the commission (working group) organizes the work of the commission (working group).

By doing official duties during the inspection, members of the commission (working group) report to the head of the commission (working group).

IV. Check procedure

13. On the day the inspection begins, the head, members of the commission (working group) present to the head of the medical organization (the person replacing him) a copy of the order of the territorial fund to conduct an inspection, service certificates.

14. The head of the medical organization (the person replacing him) represents the head and members of the commission (working group) to the heads of the structural divisions of the medical organization and appoints a responsible person who coordinates the work of the structural divisions of the medical organization during the inspection of the medical organization.

The head of the medical organization (the person replacing him) is obliged to provide the head and (or) members of the commission (working group) with the opportunity to familiarize themselves with the documents related to the verification issues.

15. Directions for the use of funds received by medical organizations for financial support are subject to verification:

territorial program of compulsory medical insurance (paragraph 17 of this Regulation);

measures of the regional program for the modernization of health care of a constituent entity of the Russian Federation to introduce standards for the provision of medical care, increase the availability of outpatient medical care, including that provided by specialist doctors (including measures to conduct in-depth medical examinations of adolescents) (paragraph 18 of this Regulation);

priority national project in the field of healthcare, including conducting additional medical examinations of working citizens, medical examinations of orphans and children in difficult life situations staying in stationary institutions, providing additional medical care by local general practitioners, doctors general practice(family doctors), district nurses of district general practitioners, district pediatricians and nurses of general practitioners (family doctors) (paragraphs 19-21 of this Regulation);

fulfillment of expenditure obligations of the constituent entities of the Russian Federation arising from the exercise by state authorities of the constituent entities of the Russian Federation of the delegated powers of the Russian Federation as a result of the adoption of federal laws and (or) regulatory legal acts of the President of the Russian Federation, and (or) regulatory legal acts of the Government of the Russian Federation in the field of health care citizens, and (or) arising from the adoption of laws and (or) regulatory legal acts of the constituent entities of the Russian Federation.

16. Verification of the use of compulsory medical insurance funds by a medical organization includes verification of compliance with the requirement to maintain separate accounting for operations with compulsory medical insurance funds.

17. Checking the use of funds received by medical organizations for the financial support of the territorial program of compulsory medical insurance, includes checking:

17.1. The validity of the receipt of funds by a medical organization to pay for medical care under compulsory medical insurance, including the following is checked:

availability of a license of a medical organization for the right to carry out certain types of medical activities, its validity and types of medical care and services specified in the license and accreditation certificates, and the types of medical care actually provided according to statistical documentation and consolidated accounting documents compiled on the basis of invoices, presented by a medical organization for payment for the medical care provided;

the correctness of drawing up applications for advancing medical care (in the amount of up to seventy percent of the average monthly volume of funds allocated to pay for medical care in accordance with the contract for the provision and payment of medical care under compulsory medical insurance) and the timeliness of sending these applications (by the 10th date of the current month);

the correctness and timeliness of the submission by a medical organization to insurance medical organizations of a register of invoices and an invoice for payment for medical care provided to insured persons (within five working days of the month following the reporting one);

compliance of the amount of funds received to pay for medical care to the cost of medical care provided in the registers of accounts and invoices for payment for medical care provided by the medical organization (taking into account the results of monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance). When checking, the facts of the funds received to pay for medical care on invoices and registers of invoices with violations in their execution and presentation for payment by a medical organization are reflected in accordance with section 5 of the List of grounds for refusing to pay for medical care (reducing payment for medical care), which is Appendix 8 to the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance (hereinafter referred to as the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care), approved by order of the Federal Fund dated 01.12.2010 N 230 "On approval of the procedure for organizing and monitoring the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance" (registered by the Ministry of Justice of the Russian Federation on January 28, 2011, registration N 19614) (as amended by the Order of the Federal Fund of August 16, 2011 N 144) (registered by the Ministry of Justice of the Russian Federation on 09.12.2011, registration N 22523), and to pay for medical care when collecting fees from insured persons (as part of voluntary medical insurance or in the form of paid services) for the medical care provided under the territorial program of compulsory medical insurance (clause 1.4 of the List of grounds for refusing to pay for medical care (reducing the payment for medical care), which is Appendix 8 to the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care);

availability of acts of reconciliation of settlements between a medical organization and insurance medical organizations (according to the form of a Standard contract for compulsory medical insurance for the provision and payment of medical care, approved by order of the Ministry of Health and Social Development of the Russian Federation of December 24, 2010 N 1184n (registered by the Ministry of Justice of the Russian Federation on 04.02. 2011, registration N 19714), reconciliation of calculations by the insurance medical organization and the medical organization is carried out monthly on the 1st day of the month following the reporting one, and also annually as of the end of the financial year, based on the results of which an act is drawn up on acceptance for payment of the medical care provided , confirming the amount of the final settlement between the parties);

existence, duration and size of accounts receivable and accounts payable on payment of medical care, reasons for the debt;

availability and validity of claims of the medical organization to insurance medical organizations in terms of payment for medical care under compulsory medical insurance;

the presence of claims and (or) claims of insurance medical organizations against a medical organization in order to compensate for the harm caused to the insured person, and sanctions applied to the medical organization.

17.2. Compliance with the obligation of a medical organization to use the funds of compulsory medical insurance received for the provided medical care in accordance with the territorial program of compulsory medical insurance, including:

1) by types of medical care;

2) according to the structure of the tariff for payment for medical care, including:

implementation of labor costs and accruals for wage payments: correct accrual and payment wages in accordance with the established rates, official salaries and actual hours worked, the validity of the payment of various allowances and additional payments for combining professions and positions, etc. (all documents confirming the validity of the payments made are checked: staffing, pay lists, documents confirming the qualifications of specialists, work schedules of structural divisions and employees, orders on personnel, labor agreements, collective agreement, regulation on wages, etc.) , checking primary accounting documents on the expenditure of compulsory health insurance funds for payments (salary, bonuses, additional payments, incentives, material aid), payment of taxes and insurance premiums established by the legislation of the Russian Federation. When checking, cases of spending the funds of compulsory medical insurance on payments (wages, bonuses, additional payments, incentives, material assistance) to persons not participating in the implementation of the territorial program of compulsory medical insurance are reflected;

incurring expenses for the purchase of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, etc. inventories, to pay for the cost of laboratory and instrumental studies conducted in other institutions (in the absence of a laboratory and diagnostic equipment in a medical organization), catering (in the absence of organized catering in a medical organization) (when checking, the amounts of expenses incurred are compared (including for the purchase drugs, consumables, food, soft inventory, medical instruments, reagents and chemicals, other inventories) with an approved cost estimate).

Verification of the use of funds for these purposes is carried out by checking primary documents confirming the legality of banking operations, including contracts for the supply of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, and other inventories.

Checked:

reasonableness of prices when purchasing goods (works, services) at the expense of compulsory medical insurance;

compliance with the terms of delivery and payment, compliance of the amounts specified in the contracts with the actual costs incurred;

timeliness, completeness and correctness of posting medicines and consumables, food, soft inventory, medical instruments, reagents and chemicals, other inventories;

safety, accounting and write-off of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, other inventories;

availability of separate accounting for medicines purchased at the expense of compulsory medical insurance and at the expense of funds received by a medical organization from other sources.

An analysis of purchased medicines is carried out (the presence of expired medicines is reflected).

Studied:

materials of the inventory of property and financial obligations carried out by a medical organization (during the audit, a selective inventory of fixed assets, inventories acquired at the expense of compulsory medical insurance funds can be carried out);

availability, duration and size of receivables and payables with suppliers of goods and services at the expense of compulsory medical insurance, timeliness of collection accounts receivable and repayment of accounts payable, conducting mutual reconciliations in settlements with suppliers, the correctness of keeping records of these calculations, the timeliness of collecting the amounts of identified shortages and theft of funds from compulsory medical insurance, material assets, acquired at the expense of compulsory medical insurance, as well as losses from damage to these values, attributed to the perpetrators.

If there are other areas of spending in the accepted tariffs for paying for medical care, the use of compulsory medical insurance funds for these purposes is checked taking into account the relevant documents regulating the procedure for carrying out such expenses, the amount of funds provided for these expenses as part of the accepted tariffs for paying for medical care and the approved cost estimate, the terms of the concluded contracts.

When conducting an audit of the use of compulsory health insurance funds:

the correctness of the reflection in the accounting registers of operations on the means of compulsory medical insurance, the correctness of the reflection of income and expenses in accordance with the current budget classification, compliance with the order of conduct cash transactions and cash accounting (in terms of compulsory medical insurance funds), the timeliness of posting cash compulsory medical insurance funds received from the bank and other sources, as well as their intended use, the availability of supporting documents and the reliability of the data contained in them, which are the basis for writing off expenses on the cash desk, the legality of the expenses incurred in terms of compulsory medical insurance funds, ensuring the safety of funds.

17.3. Availability and reliability of personalized records of information about medical care provided to insured persons, transferred by a medical organization to the territorial fund and insurance medical organizations, which are necessary, among other things, to control the use of compulsory medical insurance funds.

17.4. The use by a medical organization of funds received from the financial provision reserve for preventive measures of an insurance medical organization, including the availability of reporting documents on funds received by a medical organization from the financial provision reserve for preventive measures.

17.5. Reliability and timeliness of submission of reports by a medical organization on the use of compulsory medical insurance funds in accordance with established forms.

18. Verification of the use of funds received for financial support of the activities of the regional program for the modernization of healthcare of a constituent entity of the Russian Federation (hereinafter referred to as the Modernization Program) for the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures for conducting in-depth medical examinations adolescents), includes checking:

additional agreements to contracts for the provision and payment of medical care under compulsory health insurance on the interaction of the parties in the implementation of the Modernization Program;

provision by a medical organization to an insurance medical organization of a separate account and a register of accounts (or a separate account within the register of accounts for payment for medical care under the territorial program of compulsory medical insurance) for payment for medical care under the Modernization Program at the expense of the budget of the Federal Fund;

implementation of activities carried out at the expense of funds received for the implementation of standards, increasing the availability of outpatient medical care, and compliance with the conditions for using funds received to increase the availability of outpatient medical care from the budget of the Federal Fund, in accordance with the Decree of the Government of the Russian Federation dated February 15, 2011 N 85 "On the Approval of the Rules for Financial Support in 2011-2012 of Regional Programs for the Modernization of Healthcare in the Subjects of the Russian Federation at the expense of funds provided from the budget of the Federal Compulsory Medical Insurance Fund" (as amended by Decree of the Government of the Russian Federation of April 6, 2012 N 286) (Collected Legislation of the Russian Federation , 2011, N 8, item 1126);

compliance with the conditions for the use of funds received for the implementation of standards from the budget of the Federal Fund, in accordance with tariff agreement and the procedure for implementing the Modernization Program and spending funds for the Modernization Program, approved in the territory of the constituent entity of the Russian Federation;

implementation of measures and compliance with the conditions for the use of funds received under the Modernization Program from the budget of the territorial fund and the budget of the constituent entity of the Russian Federation (if such funds are provided), in accordance with the tariff agreement and the procedure for implementing the Modernization Program and spending funds for the Modernization Program, approved on the territory of the constituent entity Russian Federation.

When checking the use of funds received for the financial support of the Modernization Program, the following are checked:

1) documents confirming the validity of spending funds, including:

licenses for the provision of medical services as part of the activities of the Modernization Program to introduce standards for the provision of medical care, increase the availability of outpatient medical care, including that provided by specialist doctors (including measures to conduct in-depth medical examinations of adolescents);

valid certificates for medical workers providing outpatient medical care, medical services as part of medical care activities in accordance with approved standards, participating in in-depth medical examinations of adolescents;

local documents that determine the procedure and conditions for remuneration of medical workers as part of the implementation of the Modernization Program measures to introduce standards for the provision of medical care, increase the availability of outpatient medical care, including that provided by medical specialists (including measures to conduct in-depth medical examinations of adolescents);

additional agreements to employment contracts concluded between the medical organization and its employees in terms of the implementation of the Modernization Program;

2) the validity of payroll, the correctness of its calculations and the timing of payment, the implementation of the payment of taxes and insurance premiums established by the legislation of the Russian Federation;

3) compliance with the procedures provided for by the Federal Law of July 21, 2005 N 94-FZ "On placing orders for the supply of goods, performance of work, provision of services for state and municipal needs" (Sobranie Zakonodatelstva Rossiyskoy Federatsii, 2005, N 30, art. 3105; 2006, N 1, item 18; N 31, item 3441; 2007, N 17, item 1929; N 31, item 4015; N 46, item 5553; 2008, N 30, item 3616; N 49 , item 5723; 2009, N 1, item 16; N 1, item 31; N 18, item 2148; N 19, item 2283; N 27, item 3267; N 29, item 3584; N 29, item 3592; N 29, item 3601; N 48, item 5711; N 48, item 5723; N 51, item 6153; N 52, item 6441; 2010, N 19, item 2286; No. 19, article 2291; No. 31, article 4209; No. 45, article 5755; 2011, No. 15, article 2029; No. 17, article 2320; No. 27, article 3880; No. 29, article 4291 ; N 48, item 6727; N 50, item 7360; N 51, item 7447; N 48, item 6728; N 50, item 7359), when determining suppliers of medicines and consumables, soft inventory, products nutrition and other material supplies as part of the implementation of the Modernization Program for the introduction of standards for the provision of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures to conduct in-depth medical examinations of adolescents), the conclusion and execution of state (municipal) contracts, compliance terms of delivery and payment;

4) the timeliness of the formation and reliability of the data of the reports of the medical organization on the use of funds for the purposes of implementing the regional healthcare modernization program (according to the forms approved by the order of the Federal Fund of December 16, 2010 N 240 "On approval of the Procedure and form for reporting on the use of funds for the purposes of implementing regional programs for the modernization of health care of the constituent entities of the Russian Federation in the period 2011 - 2012" (registered by the Ministry of Justice of the Russian Federation on December 31, 2010, registration N 19503), and by order of the Ministry of Health and Social Development of the Russian Federation of December 30, 2010 N 1240n "On approval of the procedure and form reporting on the implementation of activities of regional programs for the modernization of healthcare in the constituent entities of the Russian Federation and programs for the modernization of federal state institutions providing medical care" (registered by the Ministry of Justice of the Russian Federation on February 1, 2011, registration N 19655);

5) the amount of allocated funding and cash expenses, in the presence of unused or unallocated funds - indicate the reasons for deviations;

6) separate reflection in accounting of receipts and expenditures of funds within the framework of the Modernization Program for each source of financial support with the maintenance of analytical accounting on sub-accounts.

19. Verification of the use of funds received by a medical organization from the budget of the territorial fund for additional medical examinations of working citizens.

When checking the use of funds received for financial support for additional medical examinations of working citizens, the following are checked:

licenses for all types of medical activities necessary for additional medical examination of working citizens;

a list of employees involved in the additional medical examination of working citizens;

contracts concluded by the inspected medical organization with a medical organization licensed for types of medical activities that are not in the inspected medical organization. Compliance of the term of the contract with the term of the actual performance of work;

estimate of income and expenses on funds received from the budget of the territorial fund for additional medical examinations of working citizens, execution of estimates of income and expenses;

2) targeted use of the funds received for additional medical examination of working citizens in the established areas of spending;

3) making payments of wages at the expense of funds received for additional medical examination of working citizens, in accordance with the timesheets;

4) the reliability of filling out the reporting form on the use of funds received for additional medical examination of working citizens;

5) separate reflection in accounting of receipts and expenditures of funds for additional medical examination of working citizens;

6) the number of working citizens who have undergone additional medical examination according to the lists of the medical organization and according to the registers of invoices for payment of the additional medical examination of working citizens.

During the inspection, a random check of the Registration Cards for additional medical examination of a working citizen can be carried out ( accounting form N 131 / y-DD-10, approved by order of the Ministry of Health and Social Development of the Russian Federation of 04.02.2010 N 55n "On the procedure for additional medical examination of working citizens" (registered by the Ministry of Justice of the Russian Federation on 04.03.2010, registration N 16550) (as amended order of the Ministry of Health and Social Development of the Russian Federation of 03.03.2011 N 163n) (registered by the Ministry of Justice of the Russian Federation on 03/28/2011, registration N 20308) (as amended by the order of the Ministry of Health and Social Development of the Russian Federation of 01/31/2012 N 70n) (registered by the Ministry of Justice of the Russian Federation of Justice of the Russian Federation on February 22, 2012, registration N 23309) (hereinafter - order N 55n) and the corresponding outpatient medical records (registration form N 025 / y-04, approved by order of the Ministry of Health and Social Development of the Russian Federation of November 22, 2004 N 255 " On the Procedure for Providing Primary Health Care to Citizens Eligible for a Set of Social Services" (registered by the Ministry of Justice of the Russian Federation on December 14, 2004, registration N 6188), which determines the validity of the use of funds, taking into account:

the completeness of the scope of the additional medical examination (completed case) and the correctness of the medical documentation by specialist doctors, compliance with the examination algorithm by specialist doctors;

compliance of the conclusions of medical specialists who carry out examinations in the Record Card for additional medical examination of a working citizen and the Medical card of an outpatient;

compliance of the specialties of doctors performing examinations with the specialties approved by order N 55n.

20. Verification of the use of funds received by a medical organization for financial support for medical examinations of orphans and children in difficult life situations staying in stationary institutions.

When checking the use of funds received to financially support the medical examination of orphans and children in difficult life situations staying in stationary institutions, the following are checked:

1) documents confirming the validity of spending funds for the specified purposes, including:

licenses for the types of medical activities necessary for the medical examination of orphans and children in difficult life situations staying in stationary institutions;

a list of employees involved in the medical examination of orphans and children in difficult life situations staying in stationary institutions;

contracts concluded by the inspected medical organization with a medical organization licensed for types of medical activities that are not in the inspected medical organization, compliance of the term of the contract with the term of the actual performance of work;

estimate of income and expenses on funds received from the budget of the territorial fund for medical examination of orphans and children in difficult life situations staying in stationary institutions, execution of estimates of income and expenses;

2) separate reflection in accounting of the receipt and expenditure of funds for medical examination of orphans and children in difficult life situations staying in stationary institutions;

3) targeted use of the funds received for the medical examination of orphans and children in difficult life situations staying in stationary institutions, according to the established areas of spending;

4) the reliability of the data of the reporting form on the use of funds received for medical examination of orphans and children in difficult life situations staying in stationary institutions;

5) making payments of wages at the expense of funds received for the medical examination of orphans and children in difficult life situations staying in stationary institutions, in accordance with the timesheets;

6) the number of children who have undergone medical examination, according to the lists of the medical organization and according to the registers of invoices for payment for the medical examination of orphans and children in difficult life situations staying in stationary institutions.

During the audit, a random check of the Medical examination cards of orphans and children in difficult life situations staying in stationary institutions can be carried out (registration form N 030-D / s / 09-10, approved by order of the Ministry of Health and Social Development of the Russian Federation dated 03.03 .2011 N 162n "On conducting medical examinations of orphans and children in difficult situations" (registered by the Ministry of Justice of the Russian Federation on 04/08/2011, registration N 20446) (hereinafter - order N 162n) and the relevant medical records of the child , at which the validity of the use of funds is determined, taking into account:

the completeness of the scope of the medical examination (finished case) and the correctness of the execution of medical documentation by specialist doctors, compliance with the examination algorithm by specialist doctors;

conformity of the conclusions of medical specialists who carry out examinations in the Medical examination card of orphans and children in difficult life situations staying in stationary institutions, the child's medical record;

compliance of the specialties of doctors performing examinations with the specialties approved by order N 162n.

21. Verification of the use of funds received by a medical organization from the budget of the territorial fund for the provision of additional medical care provided by district general practitioners, district pediatricians, general practitioners (family doctors), district nurses, district general practitioners, district pediatricians , nurses of general practitioners (family doctors) (hereinafter referred to as additional medical care):

When checking the use of funds received by a medical organization from the budget of the territorial fund for the provision of additional medical care, the following are checked:

the medical organization has licenses to provide appropriate medical care;

availability of an open separate account for accounting for funds allocated to pay for additional medical care;

availability of a budget request and an annex to it;

documents confirming the validity of the inclusion of employees of a medical organization in the budget application, information in the annex to the application, documents confirming the registration of labor relations between the employee and the medical organization (number of attached population, order on the number of created sites, order for employment, work book, staffing table and etc.);

availability of executed additional agreements to labor contracts (from the 1st working day of the month) between the medical organization and medical workers primary link for the provision of additional medical care;

making payments in accordance with the application (staffing, time sheet, payroll, calculations for accruals for payments in accordance with the law);

reflection of transactions for settlements for additional medical care in accounting;

reliability of the data of the reporting form on the use of funds received for additional medical care.

22. Verification of the implementation of measures to eliminate violations and shortcomings identified by previous inspections, including compliance with the deadlines for the return (reimbursement) by the medical organization of funds used for other purposes to the budget of the territorial fund and (or) payment of penalties based on the results of inspections previously conducted by the territorial fund (if any).

V. Registration of the act of verification

23. Based on the results of the audit, an audit report is drawn up, including:

23.1. The heading part, which indicates the name of the subject of the check, the full name of the medical organization and the date the act was drawn up.

number and date of the order of the territorial fund on the inspection;

surnames, initials and positions of the head and members of the commission (working group) who conducted the audit;

date of commencement and completion of the audit (the date of commencement of the audit, which is reflected in the content of the audit report, is the date of commencement of the work of the commission (working group), and the end date is the date of signing the audit report by the head and members of the commission (working group) who conducted the audit, according to the order for the inspection);

the name of the audit topic with an indication of the nature of the audit (scheduled / unscheduled, comprehensive);

period under review;

surnames, initials of the head of the medical organization, deputy head of the medical organization, chief accountant and other officials of the medical organization, who during the audited period had the right of the first (second) signature. If there are changes in the audited period in the composition of the above-mentioned persons, their list is given with a simultaneous indication of the period during which these persons held the relevant positions in accordance with orders, orders for their appointment to a position and dismissal from their position;

a list and details of all accounts of the medical organization (including accounts closed on the date of the audit, but active in the audited period) used by the audited medical organization, indicating the balances of funds at the start and end of the audited period, as well as at the start date of the audit;

information about the license (number, date of issue and expiration date);

other data necessary to fully characterize the medical organization, including the inspection report briefly reflects information on previous inspections of the use of compulsory medical insurance funds by the medical organization by the control authorities, on the date and period under review during the previous inspection by the territorial fund, on the elimination (non-elimination) of shortcomings and violations identified by the previous audit, if they are not eliminated, the reasons are indicated;

information on the method of conducting the check in terms of the degree of coverage of primary documents (continuous, selective) indicating which documentation was checked in a continuous and which selective way;

a description of the audited issues of the use of compulsory medical insurance funds in accordance with the audit program (if necessary, based on the specific circumstances of the audit, the audit report may contain information on issues and periods of activity of the medical organization that are not included in the audited period and the audit program).

The results of the audit are set out in the audit report on the basis of verified data and facts, confirmed by documents, the results of the audits and actual control procedures, and other actions related to the audit.

The description of the facts of violations and deficiencies identified during the audit (including the facts of misuse of compulsory medical insurance funds) must contain mandatory information on specifically violated norms of legislative, other regulatory legal acts or their individual provisions, indicating for what period violations were committed, when and what they expressed, the amounts of documented non-target expenses and expenses incurred in violation of legislative and other regulatory legal acts.

In the audit report, it is not allowed to include various kinds of conclusions, assumptions and facts that are not confirmed by primary and reporting documents.

In case of non-submission or incomplete submission of documents for the inspection by the medical organization, a list of them is given in the inspection report.

The volume of the verification act is not limited to the number of pages.

23.3. The final part, which includes generalized information on the results of the audit, indicating the identified violations and shortcomings and the deadlines for their elimination or the deadlines for submitting an action plan to eliminate the identified violations and shortcomings.

If there are facts of misuse of compulsory medical insurance funds identified during the audit, the final part of the act includes generalized information on the directions and amounts of misuse of compulsory medical insurance funds, with a requirement to return the funds used for other purposes by the medical organization and pay a fine for the misuse by a medical organization of funds transferred to it under a contract for the provision and payment of medical care under compulsory medical insurance, in accordance with Part 9 of Article 39 of Federal Law N 326-FZ.

23.4. The certification part, including the names, initials, positions and signatures of the head and members of the commission (working group) who conducted the verification of the use of compulsory medical insurance funds, the names, initials, positions and signatures of officials of the verified medical organization.

24. The act of verification is drawn up in two copies, having the same force. The head of the medical organization (the person replacing him) shall submit the act of inspection in two copies for review and signing no later than 1 (one) day before the end of the inspection period determined by the order of the territorial fund on the inspection.

One copy of the signed inspection certificate is handed over to the head of the medical organization (the person replacing him), the second copy is submitted to the territorial fund.

In a copy of the inspection report, which is submitted to the territorial fund, a record is made of the receipt of one copy of the inspection report by the head of the medical organization (the person replacing him). Such a record must contain, among other things, the date of receipt of the verification report, the signature of the person who received the verification report, and the transcript of this signature.

The date of receipt of the act by the head of the medical organization (the person replacing him) is considered the date of completion of the audit.

In case of refusal of the head of the medical organization (the person replacing him) to sign and (or) receive the inspection report by the head of the commission (working group), at the end of the inspection report, a record is made about the refusal to sign the inspection report or about the refusal to sign in receiving the verification report.

If the head of the medical organization (the person replacing him) refuses to sign and receive the inspection report, the date of completion of the inspection and the date of receipt of the inspection certificate is the sixth working day from the date of sending the inspection report to the address of the medical organization by registered mail with a return receipt.

A document confirming the fact of sending the inspection report to the medical organization is attached to the inspection materials.

In case of disagreement with the inspection act (or its individual provisions), the head of the medical organization (the person replacing him) who signs it, makes a note that the act is signed with objections that are attached to the inspection act or sent to the territorial fund no later than 5 (five) working days from date of receipt of the inspection certificate. Written objections of the medical organization to the inspection report shall be attached to the inspection materials.

In the event that the officials of the medical organization refuse to sign the inspection report or to receive the inspection report and (or) fail to submit written objections to the inspection report, the end date of the inspection is considered the sixth working day from the date of sending the medical organization of the inspection report by registered mail with a return receipt.

25. The following shall be attached to the inspection report in case of violations and shortcomings:

tables of necessary calculations;

copies of documents confirming the facts of violations and shortcomings;

materials that are important for confirming the facts of violations and shortcomings reflected in the act;

other necessary materials.

All applications drawn up during the inspection must be signed by the head or member of the commission (working group) and the head (person replacing him) of the medical organization being inspected (with visas page by page).

Copies of documents confirming the violations identified during the audit, including violations in the use of compulsory medical insurance funds, are certified by the signature of the head of the medical organization or the chief accountant of the medical organization and the seal of the medical organization. If necessary, it is allowed to compile a register of primary documents confirming violations, including violations in the use of compulsory medical insurance funds, which is signed by the head or member of the commission (working group) and the head of the medical organization (a person replacing him) or the chief accountant of the medical organization (with visas page by page) and certified by the seal of the medical organization.

If there are attachments, the text of the inspection report must contain mandatory references to them, and before the certification part of the inspection report, a list of attachments is given indicating the number of sheets, copies, and a record is made that the attachments are an integral part of the inspection report.

VI. Implementation of test results

26. Not later than 10 (ten) working days after the end of the audit, the head of the commission (working group) submits to the director (deputy director) of the territorial fund a memo on the results of the audit of the use of compulsory medical insurance funds by a medical organization.

27. The return (reimbursement) of funds, including those used for other purposes, and (or) the payment of fines, penalties is carried out by a medical organization on the basis of the received act in the manner determined by Federal Law N 326-FZ.

28. If there are written objections to the audit report, no later than 5 (five) working days from the date of their receipt, the territorial fund sends a written message to the head of the medical organization on the results of consideration of objections to the audit report, prepared by the structural unit of the territorial fund responsible for organizing the specific verification, signed by the director (deputy director) of the territorial fund, indicating the grounds on which objections are recognized as unfounded, or on the recognition of justified objections (partially justified objections) of a medical organization.

In the event that the objections are not recognized as justified or the objections of the medical organization are partially recognized as justified, the written message includes information that the terms for eliminating the violation and (or) the terms for the return (reimbursement) of funds, including those used for other purposes, and (or) the payment of fines , penalties are calculated from the date of presentation of the relevant claim by the territorial fund.

A written report on the results of consideration of objections to the inspection report is handed over to the head of the medical organization or a person authorized by him, against receipt, or sent to the medical organization by registered mail with acknowledgment of receipt.

A copy of the written report of the territorial fund on the results of consideration of the medical organization's objections to the inspection report and a document confirming the fact that the said written message was sent to the medical organization are attached to the audit materials.

In case of disagreement with the result of consideration by the territorial fund of objections to the act of inspection, the medical organization has the right to appeal this decision in a pre-trial and (or) judicial procedure.

29. The Territorial Fund ensures control over the implementation of the results of the audit, including the following:

control over the submission and implementation of the action plan to eliminate the identified violations and shortcomings (in the event that the territorial fund establishes a deadline for the elimination of violations and shortcomings, control over the elimination of the identified violations and shortcomings within the prescribed period);

control over the return (reimbursement) of funds used for other purposes;

control over the payment of fines, penalties;

accrual of penalties and sending a written notice to the medical organization about the need to pay penalties (with the calculation of the amount of penalties attached).

30. In case of detection of facts of violation of the legislation on compulsory medical insurance, requiring immediate measures to eliminate them, in case of non-fulfillment by the medical organization of the requirements of the territorial fund for the return (reimbursement) of funds, including those used for other purposes, and (or) for payment fines, penalties, as well as in case of failure to eliminate the identified violations within the established time limits, the territorial fund has the right to send relevant information and verification materials to law enforcement and judicial authorities to bring the perpetrators to justice.

VII. Final provisions

31. Inspection plans, programs of scheduled and unscheduled inspections (standard inspection programs), inspection materials, consisting of original copies of inspection certificates and properly executed annexes to them, to which references are given in inspection certificates, as well as documents provided for in Chapter VI of this Regulation, are completed, recorded and stored in the manner prescribed by the legislation on archiving in the Russian Federation and the rules of office work in the territorial fund.

The rights and obligations of insurance medical organizations are determined in accordance with agreements on financial provision of CHI and for the provision and payment of medical care under compulsory medical insurance.
Under the agreement on the financial provision of compulsory medical insurance, the insurance medical organization undertakes to pay for medical care provided to insured persons in accordance with the conditions established by the territorial program of compulsory medical insurance, at the expense of targeted funds.
The agreement on the financial provision of compulsory medical insurance must contain provisions providing for the following obligations of the insurance medical organization:
- registration, re-issuance, issuance of a compulsory medical insurance policy;
- keeping records of insured persons, compulsory medical insurance policies issued to them, as well as ensuring the accounting and safety of information received from medical organizations in accordance with the procedure for maintaining personalized records established by the authorized federal executive body;
- collection, processing of personalized records of information about insured persons and personalized records of information about medical care provided to insured persons, ensuring their safety and confidentiality, exchanging said information between subjects of compulsory medical insurance and participants in compulsory medical insurance in accordance with this Federal Law;
- informing insured persons about the types, quality and conditions for providing them with medical care by medical organizations, about identified violations in the provision of medical care to them, about their right to choose a medical organization, about the need to apply for a compulsory medical insurance policy, as well as about the obligations of the insured persons in accordance with this Federal Law;
- implementation of the consideration of appeals and complaints of citizens, the implementation of activities to protect the rights and legitimate interests of the insured persons in the manner prescribed by the legislation of the Russian Federation.
An agreement for the provision and payment of medical care under compulsory medical insurance is concluded between a medical organization included in the register of medical organizations that participate in the implementation of the territorial program of compulsory medical insurance and which, by decision of the commission for the development of the territorial program of compulsory medical insurance, establishes the amount of medical care payable at the expense of compulsory medical insurance funds, and by an insurance medical organization participating in the implementation of the territorial program of compulsory medical insurance.
The contract for the provision and payment of medical care under compulsory medical insurance must contain provisions providing for the following obligations of the insurance medical organization:
1) obtaining from medical organizations the information necessary to monitor compliance with the requirements for the provision of medical care to insured persons, information on the mode of operation, types of medical care provided and other information in the amount and manner established by the contract for the provision and payment of medical care on a mandatory health insurance, ensuring their confidentiality and safety, as well as verifying their authenticity;
2) organizing the provision of medical care to the insured person in another medical organization in case the medical organization loses the right to carry out medical activities;
3) providing information about the insured person and the medical care provided to him, necessary to control the volume, timing and quality of the medical care provided, the mode of operation of this organization, the types of medical care provided.

FUNCTIONS OF MEDICAL INSURANCE ORGANIZATIONS IN THE SPHERE OF OMS
The insurance medical organization exercises its powers in accordance with the agreement on the financial provision of compulsory medical insurance concluded between the territorial fund and the insurance medical organization. Insurance medical organizations are not entitled to carry out other activities, with the exception of activities for compulsory and voluntary medical insurance, activities. Insurance medical organizations keep separate records of operations with compulsory medical insurance funds and voluntary medical insurance funds. Insurance medical organizations keep separate records of their own funds and funds of compulsory medical insurance intended to pay for medical care. Funds intended to pay for medical care and received by an insurance medical organization are targeted financing funds.

Insurance medical organizations carry out their activities in the field of compulsory medical insurance on the basis of an agreement on the financial support of compulsory medical insurance, an agreement for the provision and payment of medical care under compulsory medical insurance, concluded between an insurance medical organization and a medical organization. Insurance medical organizations are liable for obligations arising from contracts concluded in the field of compulsory medical insurance in accordance with the legislation of the Russian Federation and the terms of these contracts. Insurance medical organizations post on their official websites on the Internet, publish in the media or bring to the attention of insured persons in other ways provided for by the legislation of the Russian Federation, information about their activities, the composition of the founders (participants, shareholders), financial results activities, work experience, the number of insured persons, medical organizations operating in the field of compulsory medical insurance in the territory of a constituent entity of the Russian Federation, types, quality and conditions for the provision of medical care, violations identified at the request of insured persons in the provision of medical care, rights citizens in the field of compulsory medical insurance, including the right to choose or replace an insurance medical organization, a medical organization, the procedure for obtaining a compulsory medical insurance policy, as well as the obligations of insured persons in accordance with this Federal Law.

An insurance medical organization is included in the register of insurance medical organizations operating in the field of compulsory medical insurance on the basis of a notification sent by it to the territorial fund before September 1 of the year preceding the year in which the insurance medical organization intends to operate in the field of compulsory medical insurance. If there are no insurance medical organizations included in the register of insurance medical organizations in the territories of the constituent entities of the Russian Federation, their powers are exercised by the territorial fund until the day the activities of insurance medical organizations included in the register of insurance medical organizations begin.

The activities of medical institutions providing services under the insurance program are constantly monitored by the insurance Fund. The event improves the quality of service for insured persons within the framework of a regulated basic program. In system compulsory insurance All business entities whose activities are licensed and located in the healthcare sector can take part. Insurance supervision over medical institutions is carried out within the framework of the Compulsory Health Insurance, which is a system of measures of an economic, legal and organizational type aimed at ensuring guarantees for the provision of medical care paid from the funds of an insurance company within the framework of the basic Program.

What are the rules, procedures and features of the implementation of insurance supervision over the quality of medical care and medical services provided? What regulations Is such oversight regulated? Which organizations are authorized to conduct it? What forms of supervision are carried out and with what frequency? What is the role of HMOs in monitoring the quality of medical care under CHI? We will answer these questions in this article.

The procedure for interaction and control of participants in the insurance program

In order to realize the constitutional rights of every citizen of the Russian Federation to health care and receive free qualified assistance in any corner of the country, a system of compulsory medical insurance was introduced. To implement the action of the program, three parties are required, between which contractual relations must be formalized. The implementation of activities, as well as the procedure for the relationship between the participants, is determined by the terms of the contract. Its provisions oblige the insured person to regularly carry out mandatory insurance premiums to the insurance Fund, the medical institution - to provide assistance under the Program, and the insurance company - to pay for the services provided in accordance with the contract.

In practice, there are many disputes between participants in the insurance system. They mainly relate to the sphere of quality and competence of the services provided. The insurance company is interested in providing high level medical care, since the financing of services provided to insured persons is carried out from their funds. All problematic situations are resolved through an expert investigation.

Rules, procedure and features of insurance supervision

Features of the event related to health insurance are reflected in federal law“On Compulsory Medical Insurance” No. 326 of October 29, 2010. On its basis, Order No. 230 of December 1, 2010 was issued, which regulates the rules for conducting the control procedure. Insurance supervision over the quality of medical services is carried out in a planned or target mode. The planned event is carried out within the time limits established by the authorized body in the inspection plans. Targeted control is carried out in situations where the insured persons are dissatisfied with the quality of the services received and initiate an event by filing a complaint. It is also performed in emergencies associated with the death of the patient or with the aggravation of his condition.

Scheduled control

Before the planned event, the medical institution receives a notice from the controller about the timing and the planned program. The notification may contain recommendations with a list of documentation that needs to be prepared. The audit is carried out for all medical services belonging to the category of insured events provided from the date of the last scheduled audit.

Target control

Target control is carried out spontaneously, it may not be warned about. The check is carried out within the framework of an insured event that has distinguished itself by unpleasant features or about which a complaint has been received. Based on the results of the examination, an inspection report is drawn up and an expert opinion is drawn up. The document should reflect all identified service deficiencies, recommendations for their elimination and principles for further work. Depending on the severity of violations, sanctions or fines may be applied to the medical institution. Sanctions may consist of a reduction in payment for medical services rendered by the amount of identified violations or a ban on medical practice carried out under the compulsory medical insurance program.

Who is authorized to supervise medical organizations?

Insurance supervision of medical organizations is carried out by the FFOMS, its territorial divisions and insurance companies specializing in the field of healthcare. Any participant of the insurance Program can control the work of a medical institution. To carry out the procedure, they resort to the services of a representative of the controlling organization - an expert who must be competent in matters of an insured event and comply with the regulated requirements. An expert in medical and economic expertise must have a five-year experience as a practicing physician who has undergone special training in the field of expert activity.

More stringent requirements are imposed on an expert specializing in quality control of medical care. The work experience of a specialist must exceed ten years. His corresponding qualifications must be confirmed by an accreditation certificate or a specialist certificate. An authorized representative of the organization must undergo training in the course of expert activity, as a result of which he is included in the territorial registers of experts. Information about an accredited specialist is available on the official website of the Medical Insurance Fund.

Forms of supervision and frequency of their implementation

The control of the activities of medical institutions is carried out within the framework of targeted or planned activities aimed at verifying the compliance with the regulatory requirements of the parameters of medical and advisory services. The event is carried out with the help of such monitoring elements as:

• Medico-economic control;
• Medical and economic expertise;
• Examination of the quality of medical care.

The Compulsory Medical Insurance Fund exercises control over medical and advisory institutions located in the country, carrying out licensed activities in the field of healthcare. A prerequisite for the implementation of the measure in relation to the subject is the existence of contractual relations with the Fund and the insurance company that regulate the provision of medical care under insurance programs. During the inspection, the medical institution has no right to interfere with its conduct. Representatives of the institution are obliged to provide the expert with free access to all documents and materials necessary for the control.

Medico-economic control

In the process of implementing the measure, specialists authorized to carry out the measure establish the fact of the reliability of the information provided to the insurance company related to the amount of assistance provided. The analysis is carried out on the basis of the information contained in the register of invoices provided for payment by the insured. This article also checks the calculation of payment for services, with a focus on contractual conditions and the regulated tariffs used in the calculation.

Medical and economic expertise

Such an examination of the provision of medical care contributes to the formation of an effective tariff policy in insurance medicine, strengthens control over the availability and quality of medical care. In the course of the medical and economic examination, authorized persons carry out analytical work to establish the correspondence between the actual and standard parameters. The parameters of the term and volume of medical care provided are compared with the data reflected in the reporting documents.

Examination of the quality of medical services

Examination allows to identify violations committed in the provision of medical services. The event contributes to improving the quality of service for insured persons. The reputation of a medical institution depends on its result, which influences the decision of participants in the compulsory health insurance program to be served in a medical institution.

An example of an examination of the quality of medical services

The Insurance Fund received a complaint against the doctor Tarasov N.N., whose untimely actions led to complications of the disease of citizen Ignatov A.A. On the basis of a claim to a medical institution, a specialist, MD, was sent to clarify the circumstances and conduct an investigation. Petrovsky I.P. During the control, a number of violations were revealed, consisting in the irresponsible attitude of employees to their duties. The expert drew up a conclusion on the basis of which sanctions were applied to the medical organization (City Clinical Hospital No. 2 of B.) in the form of a reduction in the financing of payment for medical services by the amount of the specified damage due to incompetent actions of the medical staff.

It should be noted that such an examination can only be carried out by a doctor included in the regional or federal register of experts. At the same time, he can conduct supervision only within the framework of the specialization in which he works and has a valid license or accreditation. Thus, a neurologist can conduct an examination of the quality of medical care only in the field of neurology. At the same time, quality control of expert works can be planned or targeted. The order of initiation and the nuances of the event are discussed in the table below.

Table - Types of quality examination and the frequency of their conduct

Type of expertise	Description	Frequency of holding
target	After the insured event is submitted for payment, an examination must be carried out within a month. Control is carried out immediately in the following situations: Complaint of the insured person about the quality and availability of medical services in a particular medical institution; The need to confirm the parameters of the provision of medical care in cases put on a special record after the control or examination; Death of a patient while providing treatment services; Infection of patients in the hospital; Complication of the disease	Target examinations are not limited by quantitative criteria. The parameter corresponds to the number of cases requiring investigation
Planned	The event is held in order to assess the parameters of medical care for insured persons identified by group characteristics. During the procedure, the compliance of services with the regulated requirements of the insurance program is monitored	The procedure is carried out in each medical institution at least once a year. The timing of the event is determined by the inspection plan

Thus, all forms of supervision are a set of measures aimed at assessing the activities of a medical organization or the services it provides to the requirements of the legislation of the Russian Federation. In accordance with the norms of the law, the supervisory authority or the expert is obliged to notify the organization of the inspection at least 24 hours before it starts.