1. Control of the volumes, terms, quality and conditions for the provision of medical care by medical organizations in the amount and on the terms established by the territorial program of compulsory medical insurance and the contract for the provision and payment of medical care under compulsory medical insurance is carried out in accordance with the procedure for organizing and conducting control volumes, terms, quality and conditions for the provision of medical care, established by the Federal Fund.

2. Control of volumes, terms, quality and conditions of providing medical care is carried out by conducting medical and economic control, medical and economic examination, examination of the quality of medical care.

3. Medico-economic control - establishing the compliance of information on the volumes of medical care provided to insured persons on the basis of invoice registers provided for payment by a medical organization to the terms of contracts for the provision and payment of medical care under compulsory medical insurance, the territorial program of compulsory medical insurance, methods of payment for medical care and medical care rates.

4. Medical and economic expertise - establishing the compliance of the actual terms of medical care, the volume of medical services presented for payment with the records in the primary medical documentation and accounting and reporting documentation medical organization.

5. Medical and economic expertise is carried out by a specialist expert who is a doctor who has at least five years of experience in the medical specialty and who has undergone appropriate training in expert activities in the field of compulsory medical insurance.

6. Examination of the quality of medical care - identifying violations in the provision of medical care, including an assessment of the timeliness of its provision, the correct choice of methods for prevention, diagnosis, treatment and rehabilitation, the degree of achievement of the planned result.

7. Examination of the quality of medical care is carried out by an expert on the quality of medical care included in the territorial register of experts on the quality of medical care. An expert in the quality of medical care is a specialist doctor who has a higher education, a certificate of accreditation of a specialist or a certificate of a specialist, at least 10 years of experience in the relevant medical specialty and who has been trained in expert activities in the field of compulsory medical insurance. federal fund, the territorial fund, the insurance medical organization, in order to organize and conduct an examination of the quality of medical care, entrust the conduct of the said examination to an expert on the quality of medical care from among the experts on the quality of medical care included in the territorial registers of experts on the quality of medical care.

(in ed. federal law dated 02.07.2013 N 185-FZ)

(see text in previous edition)

7.1. The territorial register of medical care quality experts contains information about medical care quality experts, including last name, first name, patronymic, specialty, work experience in the specialty, and other information provided for by the procedure for maintaining the territorial register of medical care quality experts. The procedure for maintaining the territorial register of experts in the quality of medical care by the territorial fund, including the placement of this register on the official website territorial fund on the Internet, established by the Federal Fund.

8. The medical organization does not have the right to prevent experts from accessing the materials necessary for conducting a medical and economic examination, examination of the quality of medical care, and is obliged to provide the experts with the information they request.

9. The results of medical and economic control, medical and economic examination, examination of the quality of medical care are drawn up by the relevant acts in the forms established by the Federal Fund.

10. Based on the results of monitoring the volumes, terms, quality and conditions for the provision of medical care, the measures provided for in Article 41 of this Federal Law and the terms of the contract for the provision and payment of medical care under compulsory medical insurance are applied in accordance with the procedure for paying for medical care under compulsory medical insurance, established rules of compulsory health insurance.

(see text in previous edition)

11. The territorial fund, in the manner established by the Federal Fund, has the right to exercise control over the activities of medical insurance organizations by organizing control over the volume, timing, quality and conditions for the provision of medical care, to conduct medical and economic control, medical and economic examination, examination of the quality of medical care, in including repeatedly, as well as control over the use of compulsory medical insurance funds by medical insurance organizations and medical organizations. The territorial fund at the place of provision of medical care conducts medical and economic control, medical and economic examination, examination of the quality of medical care in the event that medical care is provided to insured persons outside the territory of the subject Russian Federation in which a compulsory health insurance policy was issued. Experts of the territorial fund must meet the requirements established by parts 5 and this article.

12. Based on the results of monitoring the volumes, terms, quality and conditions for the provision of medical care, the territorial fund and (or) the insurance medical organization, in the manner established by the Federal Fund, inform the insured persons about the identified violations in the provision of medical care to them in accordance with the territorial program of compulsory medical insurance .

The holder of a compulsory medical insurance policy (CHI) can count on passing all the necessary examinations within the framework of the current insurance program. According to Law No. 323-FZ of November 21, 2011 “On the Basics of Protecting the Health of Citizens in the Russian Federation”, each insured person has the right to receive medical care in a guaranteed amount free of charge in accordance with the terms of the insurance contract. Are all tests CHI free and what is included in this list?

Who pays for free tests

Medical care under the CHI policy is free only for its owner. As for hospitals and polyclinics providing outpatient and inpatient treatment to insured persons, each of these medical institutions is obliged to pay the following costs:

• maintenance of special equipment and troubleshooting;
• wages for medical workers;
• purchase of necessary reagents, tools and preparations.

All of the above insurance costs are covered by the Federal Compulsory Medical Insurance Fund (FOMS).

Rules for obtaining free analyzes

Obtaining any medical service compulsory medical insurance policy must be justified. When it becomes necessary to conduct any surveys, you need to proceed as follows:

• visit the clinic along with the compulsory medical insurance policy;
• contact a specialist of the required profile;
• get a referral for free tests.

The patient cannot independently decide which studies need to be done - this is determined by the doctor. All activities that are assigned by a specialist are done free of charge in the same clinic. If the clinic does not have the opportunity to conduct some research, the patient is sent to another medical institution.

On a note! When undergoing a course of treatment in a hospital under the CHI program, the patient has the right to receive all medical services free of charge.

How to get tested in another region

The scope of medical services under the contract compulsory insurance has some territorial restrictions. Outside their region, the insured person receives medical assistance under the terms of the basic program, which operates throughout the country. Within the boundaries of his region, he is served according to a program approved by the territorial fund compulsory medical insurance(TFOMS), which covers a wider range of services.

Rules for obtaining medical assistance under compulsory medical insurance in another region:

• during departure, the policy should be with you - it is better to take a picture of it and save the photo on your phone so that you can present it to health workers at least in this form;
• when they refuse to conduct a particular study on a free basis, explaining that this is not provided for by the basic program, you need to look into Art. 35 of the Federal Law No. 326-FZ of November 29, 2010 “On Compulsory Medical Insurance in the Russian Federation” (hereinafter - Federal Law No. 326). If the basic program does not provide for this type of examination, then the refusal is legitimate;
• when a state institution refuses to serve, call the regional TFOMS. The phone number can be found on the website of the Federal Compulsory Health Insurance Fund. It is illegal;
• when health workers claim that they work only with specific insurers, this is also illegal, since the policy is valid throughout the country.

Good to know! Analyzes are a preventive measure, which means an insured event. This is regulated by Art. 3 of the Federal Law No. 326. In accordance with the law, free research to clarify the diagnosis should be carried out throughout the territory of the Russian Federation.

In the event of an incomprehensible situation, call your insurance company- they will tell you how to proceed. The phone number is on the back of the policy.

What tests can be taken for compulsory health insurance for free

The problem is that there is no complete and exhaustive list of free CHI studies. Specialists sometimes do not even know whether a particular study falls under the insurance program. This is due to the fact that the diagnosis of various diseases sometimes requires an individual approach. To make a specific diagnosis, there is no need to puzzle over this issue - just look at the standards of medical care.

Remark: the standards of medical care are the selection of minimum effective measures for the diagnosis and treatment of a particular disease.

In order to find out if some type of research is provided for by the CHI program, you must:

1. Look at Article 35 of Federal Law No. 326. For example, if it is necessary to diagnose or observe a disease of the eye and its adnexa (for example, astigmatism), this is included in the CHI program.
2. Next, we are looking for a standard of medical care for this disease on the website of the Ministry of Health of the Russian Federation. We select the subsection “Diseases of the eye and its adnexa” and look for the Order of the Ministry of Health “On approval of the standard for primary health care for astigmatism”. We open it and look for the desired position in the nomenclature list.

An indicative list of standard analyzes for CHI 2020:

You can see a complete list of analyzes for compulsory medical insurance in 2020.

By eco

Approximately one seventh of married couples in the Russian Federation cannot conceive a child through natural insemination. Often this is due to the peculiarities of the physiological structure of the reproductive organs or the banal incompatibility of partners. Fortunately, the state proposes to solve this problem by providing a quota for IVF, which includes both sexes with infertility.

In order to become parents through in vitro fertilization under the CHI program, it is necessary to undergo a medical examination.

List of required list of analyzes for IVF according to CHI 2020:

• general and biochemical analysis of blood and general analysis of urine;
• fluorographic examination;
• blood sampling to determine the Rh factor and group;
• hysteroscopy and pipel biopsy;
• taking smears for the composition of the microflora from the vagina and from the urethra;
• hemostasiogram;
• blood test for homocysteine;
• hormonal panel: study of the level of hormones: prolactin, TSH, T4, in case of menstrual dysfunction - FSH, cortisol (important to exclude the stress factor), estradiol, metanephrine and normetanephrine.
• blood sampling to detect TORCH infections (syphilis, HIV, hepatitis, herpes);
• PCR of vaginal discharge for herpes virus and cytomegalovirus;
• microbiological analysis for chlamydia, mycoplasma, ureaplasma is also included in the compulsory medical insurance policy for IVF;
• smear cytology from the cervix and cervical canal;
• detection of antibodies to the rubella virus;
• Ultrasound of the pelvic organs and the thyroid gland;
• Ultrasound of the mammary glands - up to 35 years, mammography - after 35 years;

Studies for men:

• blood test for TORCH infection;
• spermogram;
• PCR of discharge from the urethra for herpes virus and cytomegalovirus;
• the CHI policy also includes seeding or PCR for chlamydia, ureaplasmosis, mycoplasmosis;
• taking swabs for flora from the urethra;
• blood sampling for Rh factor and group.

The shelf life of the results of the above studies is from 3 months to one year. If there were unsuccessful IVF attempts or interrupted pregnancies before the procedure, partners are advised to undergo a blood test for a karyotype.

Details about and all sorted out in separate articles on our website.

During pregnancy

Expectant mothers also have the right to conduct tests under the compulsory medical insurance policy. To do this, you must be registered in the antenatal clinic and regularly visit your obstetrician-gynecologist.

The list of standard studies includes:

• clinical blood and urine tests;
• blood chemistry;
• allergen tests (in the presence of skin reactions and mucosal reactions)
• research for the detection of infectious diseases;
• detection of antibodies to viral infections - measles and rubella;
• blood sampling for Rh factor and group;
• blood sampling for TORCH infection;
• hormonal panel: hCG, estrogen, progesterone, prolactin.

If the doctor sees the need for any additional studies, they are carried out on a paid basis only when the clinics providing services under the CHI program do not have the appropriate equipment, tools or reagents.

Refund Policy

It happens that the insured person takes a series of tests on his own initiative, so as not to waste time visiting the clinic. Accordingly, payment for the research carried out is made from his own pocket. In such a situation, it is extremely difficult to justify the need to provide free medical services. There is still a chance to return the money spent, but for this you need to do the following:

• keep all receipts for payment for medical services provided on a paid basis;
• bring them to the insurance company and find out if the study falls under the compulsory medical insurance program;
• if the tests are included in the list of free tests, you need to write an application for a refund and indicate in it the details of your bank account for a refund.

The above algorithm will take effect only when the patient has a referral from a doctor for paid tests. Otherwise, it is almost impossible to return the spent funds, because the state cannot pay for all studies conducted without a referral, and only on the basis of the insured person's own initiative.

Important! In order to prove your case, first of all you need to know your rights. If a doctor or insurer insists that the required analysis is not included in the MHI program, this can be checked on the website of the territorial MHIF or contact regulations. Some unscrupulous health workers deliberately send patients for paid tests, and then get their share for it.

Conclusion

Summarizing the above, the following conclusion suggests itself: almost all tests prescribed by a doctor can be carried out free of charge, because there is simply no exhaustive list. The specialist acts in accordance with generally accepted norms and standards - if a certain study is necessary to confirm the diagnosis and this is supported by a legislative act, then this does not run counter to the conditions compulsory program insurance.

The patient, in turn, must: know his rights as an insured person, be able to find information of interest in legislative framework and on sites, have a policy with you and decide everything contentious issues with the insurer.

You can learn more about the system and your rights in our next article.

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Target. Understand the regulatory framework for monitoring the volume, timing, quality and conditions for the provision of medical care under CHI. Tasks:

• to study the types of control over the provision of medical care in the CHI system;
• get acquainted with the main regulatory legal acts regulating the control of the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance;
• to understand the features of medical and economic control, medical and economic examination and examination of the quality of medical care in the compulsory medical insurance system.

Basic concepts and terms. Control of the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance. Medical and economic control. Medical and economic expertise. Examination of the quality of medical care. Expert in the quality of medical care.

Questions. The concept and goals of controlling the volumes, terms, quality and conditions for the provision of medical care by medical organizations. Subjects and objects of control. Medico-economic control. Medical and economic expertise. Examination of the quality of medical care. Repeated medical and economic examination and examination of the quality of medical care.

The control of the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance (hereinafter referred to as control) includes measures to verify the compliance of the medical care provided to the insured person with the terms of the contract for the provision and payment of medical care under compulsory medical insurance in accordance with the territorial program of compulsory medical insurance, implemented through medical and economic control , medical and economic expertise and expertise of the quality of medical care.

The object of control is the organization and provision of medical care under compulsory health insurance.

The subjects of control are TFOMS, HIOs, medical organizations that have the right to exercise medical activities and included in the register of medical organizations operating in the field of CHI.

Control objectives:

• ensuring free provision of medical care to the insured person in the amount and on the terms established by the territorial CHI program;
• protection of the rights of the insured person to receive free medical care in the amount and on the terms established by the territorial CHI program, of adequate quality in medical organizations participating in the implementation of CHI programs, in accordance with contracts for the provision and payment of medical care under CHI;
• prevention of defects in medical care resulting from non-compliance of the medical care provided with the state of health of the insured person; non-compliance and / or incorrect implementation of the procedures for the provision of medical care and / or standards of medical care, medical technologies by analyzing the most common violations based on the results of control and taking measures by authorized bodies;
• verification of the fulfillment by HIOs and medical organizations of obligations to pay and provide free medical care to insured persons under compulsory medical insurance programs;
• verification of the fulfillment of HIO obligations to study the satisfaction of insured persons with the volume, availability and quality of medical care;
• optimization of expenses for paying for medical care in the event of insured event and reduction of insurance risks in CHI.

The control of the volumes, terms, quality and conditions for the provision of medical care by medical organizations in the amount and on the terms established by the territorial CHI program and the contract for the provision and payment of medical care under the CHI is carried out in accordance with the Procedure for organizing and monitoring the volumes, timing, quality and conditions for the provision of medical care under compulsory medical insurance, which was approved by order of the Federal Fund for Compulsory Medical Insurance dated 01.12.2010 No. 230.

Types of control over the volumes, terms, quality and conditions for the provision of medical care: carried out by conducting medical and economic control, medical and economic examination, examination of the quality of medical care.

Medico-economic control is the establishment of compliance of information on the volumes of medical care provided to insured persons on the basis of invoice registers provided for payment by a medical organization to the terms of contracts for the provision and payment of medical care under compulsory medical insurance, the territorial compulsory medical insurance program, methods of payment for medical care and tariffs for payment for medical care.

Medical and economic expertise - this is the establishment of compliance with the actual terms of medical care, the volume of medical services presented for payment with the records in the primary medical documentation and accounting and reporting documentation of the medical organization.

Examination of the quality of medical care - this is the identification of violations in the provision of medical care, including an assessment of the timeliness of its provision, the correct choice of methods of prevention, diagnosis, treatment and rehabilitation, the degree of achievement of the planned result.

The results of medical and economic control, medical and economic examination, examination of the quality of medical care are drawn up by the relevant acts in the forms established by the Federal Compulsory Medical Insurance Fund.

The Federal Compulsory Medical Insurance Fund of Russia has introduced new rules for controlling the volume, timing, quality and conditions of medical care paid for by compulsory medical insurance. There will be no revolutionary changes - the structure and stages of control, in general, remain the same.

Control over "cancer" medical care will change significantly. From the moment the sign "Suspicion of an oncological disease" appears, the CMO - on the information resource of the TFOMS - is obliged to form an individual history of insured events of an insured cancer patient based on registers of invoices for medical care. This history will reflect all the patient's appeals in connection with MN at all stages and levels of its provision. The MEE will evaluate the compliance of the provided oncological care with clinical recommendations, including the timeliness of diagnosis and treatment.

The IEC will identify, among other things, cases of non-inclusion / untimely inclusion in the dispensary observation group of persons with those diagnoses for which this observation is provided.

Targeted IEA will be carried out more often - the project provides additional grounds for it:

• providing medical care in the field of "oncology" with the use of chemotherapy;
• untimely registration at the dispensary;
• non-core hospitalization - that is, the hospitalization of a patient who should have been treated as planned in a hospital of a different profile according to the regional routing of patients.

The terms of the target IEE will change - a month from the date of the IEC act (now - a month from the date of submission of registers of invoices and invoices for payment). Exceptions:

• identification of a case of non-core hospitalization "over the past day". In this case, the CMO forms an expert opinion, one copy of which is sent to the head of the medical organization that issued the referral for planned hospitalization, the other to the regional health care institution to take measures to ensure specialized hospitalization;
• telemedicine assistance from national medical research centers. In this case, the MEE is carried out within two days from the date of receipt by the CMO of information about such a telemedicine consultation. And the MEE will evaluate - including - the "primary" for the records of the attending physician on the application of the recommendations of the medical workers of the NMIC, which were issued by them at the same telemedicine consultation (according to the list of diseases for which the Ministry of Health of Russia will provide a remote telemedicine consultation of the NMIC). All "defective" cases will then be transferred to the ECMP, which in this category is carried out monthly following the results of the IEE, and reveals the facts of non-compliance / incomplete implementation of the recommendations of the NMIC.

ECMP, as now, will check the compliance of the provided medical care with the MHI agreement, procedures, standards, KR and clinical practice. However, a rule is being introduced that the criteria for assessing the quality of medical care for the purposes of ECMP must be approved in accordance with Part 2 of Art. 64 of the Federal Law of November 21, 2011 No. 323-FZ "". In addition, ECMP will be practiced using a multidisciplinary approach - by several experts in several specialties.

Targeted ECMP of lethal outcomes will not always be carried out (as it is now), but only in some nosological forms: acute coronary syndrome, acute cerebrovascular accident, pneumonia, breast cancer in women. The number of targeted ECMP will increase with a patient’s repeated justified visit: if now it is carried out when applying for outpatient care within 15 days, then according to the project it will be carried out with a repeated visit within 30 days. In addition, all cases of violations in the provision of care to cancer patients identified by the MEE will be included in the ECMP.

In addition, the range of topics for thematic ECMP has expanded: it will, among other things, identify cases of non-inclusion or untimely inclusion of patients in the dispensary observation group. Such an examination can be carried out twice a year or more often.

TFOMS, HIOs and medical organizations, according to the project, should interact, including on the basis of the TFOMS software package, organized to provide information support to insured persons and integrated with information systems TFOMS on personalized accounting of information about patients and the medical care provided to them. This software package should work around the clock in online real time, and both HIOs (including insurance representatives) and medical organizations can access and use it.

It is this resource that ensures ongoing checks on the timeliness of inclusion in the dispensary observation group and the timeliness of dispensary appointments, as well as the correct routing of patients, informing them of the right to choose a medical organization and transferring them to another medical organization if necessary (everyone is checked by HMOs).

______________________________

The text of the draft order of the Federal Compulsory Medical Insurance Fund of Russia "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" and materials to it can be found on the federal portal of draft regulatory legal acts (ID: 04/15/02 -19/00088421).

"Issues of expertise and quality of medical care", 2013, N 3

What document should be used when organizing control over the volume and quality of medical care under CHI?

Answer. The main regulatory document in this area is FFOMS order dated 01.12.2010 N 230 (as amended on 16.08.2011) "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." The order defines the rules and procedure for organizing and conducting by insurance medical organizations and compulsory medical insurance funds to control the volumes, terms, quality and conditions for the provision of medical care by medical organizations in the amount and on the terms established by the territorial program of compulsory medical insurance and the contract for the provision and payment of medical care under compulsory medical insurance. It should be taken into account that in many subjects of the Russian Federation, on the basis of this document, their own similar regional orders and methodological recommendations were developed and approved.

What is meant by control of volumes, terms, quality and conditions of providing medical care under CHI?

Answer. The control of the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance (hereinafter referred to as control) includes measures to verify the compliance of the medical care provided to the insured person with the terms of the contract for the provision and payment of medical care under compulsory medical insurance, implemented through medical and economic control, medical and economic examination and examination of the quality of medical care (KMP). The object of control is the organization and provision of medical care under compulsory health insurance. The subjects of control are territorial CHI funds, insurance medical organizations, 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 CHI.

What are the main goals of control?

Answer. The main objectives of control are:

1. ensuring free provision of medical care to the insured person in the amount and on the terms established by the territorial CHI program;
2. protection of the rights of the insured person to receive free medical care in the amount and on the terms established by the territorial CHI program, of adequate quality in medical organizations participating in the implementation of CHI programs, in accordance with contracts for the provision and payment of medical care under CHI;
3. prevention of defects in medical care resulting from non-compliance of the medical care provided with the state of health of the insured person; non-compliance and / or incorrect implementation of the procedures for the provision of medical care and / or standards of medical care, medical technologies by analyzing the most common violations based on the results of control and taking measures by authorized bodies;
4. verification of the fulfillment by insurance medical organizations and medical organizations of obligations to pay and provide free medical care to insured persons under compulsory medical insurance programs;
5. checking the fulfillment by insurance medical organizations of obligations to study the satisfaction of insured persons with the volume, availability and quality of medical care;
6. optimization of expenses for paying for medical care in the event of an insured event and reduction of insurance risks in compulsory medical insurance.

What is meant by medical and economic control?

Answer. In accordance with Part 3 of Article 40 of the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation" (hereinafter referred to as the Federal Law), medical and economic control is understood to mean the establishment of compliance of information on the volume of medical care provided to insured persons on the basis of registers of accounts provided for payment by a medical organization to the terms of contracts for the provision and payment of medical care under compulsory medical insurance, the territorial program of compulsory medical insurance, methods of payment for medical care and tariffs for payment for medical care. Medico-economic control is carried out by specialists of insurance medical organizations and territorial compulsory medical insurance funds.

During medical and economic control, all cases of medical care under compulsory medical insurance are monitored in order to:

1. verification of registers of accounts for compliance with the established procedure for information exchange in the field of CHI;
2. identification of a person insured by a specific insurance medical organization (payer);
3. verification of the compliance of the provided medical care with: a) the territorial program of compulsory medical insurance; b) the terms of the contract for the provision and payment of medical care under compulsory medical insurance; c) a valid license of a medical organization to carry out medical activities;
4. checking the validity of the application of tariffs for medical services, calculating their cost in accordance with the methodology for calculating tariffs for paying for medical care, approved by the authorized person federal agency executive power, methods of payment for medical care and tariffs for payment for medical care and an agreement for the provision and payment of medical care under compulsory medical insurance;
5. establishing that the medical organization does not exceed the volume of medical care established by the decision of the commission for the development of the territorial CHI program, payable at the expense of CHI funds.

Violations detected in the registers of accounts are reflected in the act of medical and economic control, indicating the amount of reduction in the account for each entry in the register containing information about defects in medical care and / or violations in the provision of medical care. In accordance with Parts 9 and 10 of Article 40 of the Federal Law, the results of medical and economic control, drawn up by the relevant act, are the basis for applying the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care under compulsory medical insurance and a list of grounds for refusing to pay for medical assistance (reducing payment for medical care), and may also be the basis for a medical and economic examination; organizing and conducting an examination of the ILC; conducting repeated medical and economic control, repeated medical and economic examinations and examinations of the ILC by the territorial fund of compulsory medical insurance or by an insurance medical organization on the instructions of the territorial fund (except for control when making payments for medical care provided to insured persons outside the subject of the Russian Federation, on the territory of which the policy was issued OMS).

What is meant by medical and economic expertise?

Answer. Medical and economic expertise in accordance with Part 4 of Article 40 of the Federal Law - establishing the compliance of the actual terms of medical care, the volume of medical services presented for payment with records in the primary medical documentation and accounting and reporting documentation of a medical organization. Medical and economic expertise is carried out in the form of: a) targeted medical and economic expertise; b) planned medical and economic expertise.

Targeted medical and economic expertise is carried out in the following cases:

a) repeated visits for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;

b) diseases with an extended or shortened period of treatment by more than 50 percent of the established standard of medical care or the average prevailing for all insured persons in reporting period with a disease for which there is no approved standard of care;

c) receiving complaints from the insured person or his representative about the availability of medical care in a medical organization.

On the basis of the medical and economic control carried out, the planned medical and economic examination is carried out on invoices submitted for payment within a month after the provision of medical assistance to the insured person under compulsory medical insurance, in other cases it can be carried out within a year after the presentation of invoices for payment.

When conducting a planned medical and economic examination, the following are evaluated:

a) the nature, frequency and causes of violations of the rights of insured persons to receive medical care under compulsory medical insurance in the amount, terms, quality and conditions established by the contract for the provision and payment of medical care under compulsory medical insurance;

b) the volume of medical care provided by the medical organization and its compliance with the volume established by the decision of the commission for the development of the territorial program of compulsory medical insurance, payable at the expense of compulsory medical insurance;

c) the frequency and nature of violations by the medical organization of the procedure for the formation of registers of accounts.

The volume of monthly planned medical and economic examinations from the number of invoices accepted for payment for cases of medical care under compulsory medical insurance is determined by the plan of inspections by medical insurance organizations of medical organizations, agreed by the territorial fund of compulsory medical insurance, and is not less than:

8% - inpatient care;

8% - medical care provided in a day hospital;

0.8% - outpatient care.

If during the month the number of defects in medical care and / or violations in the provision of medical care exceeds 30 percent of the number of cases of medical care for which a medical and economic examination was carried out, in the next month the volume of checks from the number of invoices accepted for payment by cases provision of medical care should be increased by at least 2 times compared to the previous month.

In relation to a certain set of cases of medical care, selected according to thematic criteria (for example, the frequency and types of postoperative complications, the duration of treatment, the cost of medical services), a planned thematic medical and economic examination can be carried out in a medical organization in accordance with a plan agreed by the territorial CHI fund. .

Based on the results of the medical and economic examination, the specialist-expert draws up an act of medical and economic examination in two copies: one is transferred to the medical organization, one copy remains in the medical insurance organization / territorial CHI fund.

In accordance with Part 9 of Article 40 of the Federal Law, the results of the medical and economic examination, drawn up by the relevant act in the form established by the Federal Compulsory Medical Insurance Fund, are the basis for applying to the medical organization the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care under Compulsory medical insurance and a list of grounds for refusing to pay for medical care (reducing the payment for medical care), and may also be the basis for an examination of the ILC.

What is meant by ILC expertise?

Answer. In accordance with Part 6 of Article 40 of the Federal Law, the examination of the ILC is the identification of violations in the provision of medical care, including the assessment of the correctness of the choice of medical technology, the degree of achievement of the planned result and the establishment of causal relationships of identified defects in the provision of medical care.

Examination of the CMP is carried out by checking the compliance of the medical care provided to the insured person with the contract for the provision and payment of medical care under compulsory medical insurance, procedures for the provision of medical care and standards of medical care, and established clinical practice.

Examination of the ILC is carried out by an expert of the ILC, included in the territorial register of experts of the ILC on behalf of the territorial fund for compulsory medical insurance or an insurance medical organization.

Examination of the ILC is carried out in the form of: a) targeted examination of the ILC; b) scheduled examination of the ILC.

Target examination of the ILC is carried out in the following cases:

1. receiving complaints from the insured person or his representative about the availability and quality of medical care in a medical organization;
2. deaths in the provision of medical care;
3. nosocomial infection and complications of the disease;
4. primary access to disability of persons of working age and children;
5. repeated justified treatment for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;
6. diseases with an extended or shortened treatment period by more than 50 percent of the established standard of medical care or the average prevailing for all insured persons in the reporting period with a disease for which there is no approved standard of medical care.

When conducting a targeted examination of the ILC on cases selected based on the results of a targeted medical and economic examination, the general terms for conducting a targeted examination of the ILC may increase up to six months from the date of submission of the invoice for payment.

When conducting a targeted examination of the ILC on cases of repeated treatment (hospitalization) for the same disease, the established terms are calculated from the moment the invoice containing information on the repeated treatment (hospitalization) is submitted for payment.

The terms for conducting a targeted examination of the CMP from the moment the invoice for payment is provided are not limited in cases of complaints from insured persons or their representatives, deaths, nosocomial infections and complications of diseases, primary disability of people of working age and children.

Conducting a targeted examination of the ILC in the event of complaints from insured persons or their representatives does not depend on the time elapsed since the provision of medical care and is carried out in accordance with Federal Law No. 59-FZ of 02.05. normative legal acts regulating the work with citizens' appeals.

A scheduled examination of the CMP is carried out in order to assess the compliance of the volumes, terms, quality and conditions for the provision of medical care to groups of insured persons, divided by age, disease or group of diseases, stage of medical care and other features, conditions stipulated by the contract for the provision and payment of medical care under compulsory medical insurance . The volume of monthly scheduled examinations of the CMP is determined by the plan of inspections by insurance medical organizations of medical organizations and is not less than: in a hospital - 5% of the number of completed cases of treatment; in a day hospital - 3% of the number of completed cases of treatment; when providing outpatient care - 0.5% of the number of completed cases of treatment based on the results of medical and economic control.

The scheduled examination of the CMP is carried out on cases of medical care under compulsory medical insurance, selected: a) by random sampling; b) according to a thematically homogeneous set of cases.

A scheduled examination of the CMP by a random sampling method is carried out to assess the nature, frequency and causes of violations of the rights of insured persons to timely receive medical care of the volume and quality established by the territorial CHI program, including those caused by improper implementation of medical technologies that have led to a deterioration in the health of the insured person, an additional risk of adverse consequences for his health, non-optimal expenditure of resources of a medical organization, dissatisfaction with the medical care of insured persons.

The planned thematic examination of the CMP is carried out in relation to a certain set of cases of medical care under compulsory medical insurance, selected according to thematic criteria in each medical organization or group of medical organizations providing medical care under compulsory medical insurance of the same type or under the same conditions.

The choice of topics is based on the performance indicators of medical organizations, their structural divisions and specialized areas of activity: a) hospital mortality, the frequency of postoperative complications, the primary disability of people of working age and children, the frequency of repeated hospitalizations, the average duration of treatment, the cost of medical services and others indicators; b) the results of internal and departmental control of the ILC.

The planned thematic examination of the CMP is aimed at solving the following tasks: a) identifying, establishing the nature and causes of typical (repeating, systematic) errors in the diagnostic and treatment process; b) comparison of the CMP provided to groups of insured persons, divided by age, gender and other characteristics.

A scheduled examination of the CMP is carried out in each medical organization providing medical care under compulsory medical insurance, at least once during a calendar year, within the time limits specified by the inspection plan.

Examination of the ILC can be carried out during the period of provision of medical assistance to the insured person (hereinafter referred to as the in-person examination of the ILC), including at the request of the insured person or his representative. The main goal of the full-time examination of the CMP is to prevent and / or minimize the negative impact on the patient's health of defects in medical care.

With the notification of the administration of the medical organization, the ILC expert may conduct a tour of the divisions of the medical organization in order to control the conditions for the provision of medical care, prepare materials for an expert opinion, and also consult the insured person.

When consulting, the insured person who applied is informed about the state of his health, the degree of compliance of the medical care provided with the procedures for the provision of medical care and standards of medical care, the contract for the provision and payment of medical care under compulsory medical insurance, with an explanation of his rights in accordance with the legislation of the Russian Federation.

The expert of the ILC, who carried out the examination of the ILC, draws up an expert opinion containing a description of the conduct and results of the examination of the ILC, on the basis of which an act of examination of the ILC is drawn up.

In accordance with parts 9 and 10 of Article 40 of the Federal Law, the results of the examination of the ILC, drawn up by the relevant act in the form established by the Federal Compulsory Medical Insurance Fund, are the basis for applying to a medical organization the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care under Compulsory medical insurance and a list of grounds for refusing to pay for medical care (reducing payment for medical care).

Based on the acts of examination of the ILC, the authorized bodies take measures to improve the ILC.

How does the territorial MHI fund supervise the activities of medical insurance organizations in the field of monitoring the quality of medical care?

Answer. On the basis of Part 11 of Article 40 of the Federal Law, the Territorial CHI Fund exercises control over the activities of medical insurance organizations by organizing control over the volumes, terms, quality and conditions for the provision of medical care, conducts medical and economic control, medical and economic examination, examination of the ILC, including repeated .

Repeated medical and economic examination or examination of the ILC (hereinafter referred to as re-examination) is a medical and economic examination carried out by another specialist-expert or another expert of the ILC, an examination of the ILC in order to verify the validity and reliability of the conclusions on previously adopted conclusions made by the specialist-expert or expert of the ILC, primarily who conducted a medical and economic examination or examination of the ILC.

The re-examination of the ILC can be carried out in parallel or sequentially with the first one by the same method, but by another expert of the ILC.

The objectives of the re-examination are: a) verification of the validity and reliability of the conclusion of a specialist expert or expert of the ILC, who initially conducted the medical and economic examination or examination of the ILC; b) control over the activities of individual specialists-experts/experts of the ILC.

Re-examination is carried out in the following cases:

a) carrying out by the territorial fund of compulsory medical insurance documentary verification organizations CHI insurance medical organization;

b) detection of violations in the organization of control by the insurance medical organization;

c) groundlessness and/or unreliability of the opinion of the ILC expert who conducted the examination of the ILC;

d) receipt of a claim from a medical organization that has not been settled with an insurance medical organization.

The territorial CHI fund notifies the insurance medical organization and the medical organization of the re-examination no later than 5 working days before the start of work.

To conduct a re-examination to the territorial MHI fund, within 5 working days after receiving the relevant request, the insurance medical organization and the medical organization must provide:

insurance medical organization - copies of acts of medical and economic control, medical and economic examination and examination of the ILC necessary for the re-examination;

medical organization - medical, accounting and reporting and other documentation, if necessary, the results of internal and departmental control of the ILC, including those carried out by the health management body.

The number of cases subject to re-examination is determined by the number of reasons for their conduct, but not less than 10% of the number of all examinations for the corresponding period of time, including at least 30% of the ILC re-examinations.

During the calendar year, all insurance medical organizations operating in the field of CHI should be subject to re-examination in cases of medical care in all medical organizations in proportion to the number of invoices presented for payment.

The territorial MHI fund sends the results of the re-examination, drawn up by the act, to the medical insurance company and the medical organization no later than 20 working days after the end of the check. The insurance medical organization and the medical organization are obliged to consider these acts within 20 working days from the date of their receipt.

In the absence of agreement with the results of the re-examination, the medical insurance organization and the medical organization send a signed act with a protocol of disagreements to the territorial CHI fund no later than 10 working days from the date of receipt of the act.

The Territorial CHI Fund, within 30 working days from the date of receipt, considers the act with the protocol of disagreements with the involvement of interested parties.

In accordance with Part 14 of Article 38 of the Federal Law, in the event of violations of contractual obligations by an insurance medical organization, when it reimburses the costs of paying for medical care, the territorial CHI fund reduces payments by the amount of violations or unfulfilled contractual obligations.

The list of sanctions for violation of contractual obligations is established by the agreement on financial provision of CHI concluded between the territorial CHI fund and the insurance medical organization.

In accordance with specified contract in the event of violations in the activities of the insurance medical organization, the territorial CHI fund uses the measures applied to the insurance medical organization in accordance with Part 13 of Article 38 of the Federal Law and the agreement on the financial support of CHI or recognizes the measures applied by the insurance medical organization to the medical organization as unreasonable.

When detecting violations in the organization and conduct of the medical and economic examination and / or examination of the CMP, the Territorial CHI Fund sends a claim to the medical insurance organization, which contains information about the control over the activities of the medical insurance organization:

a) the name of the commission of the territorial CHI fund;

b) the date (period) of the inspection of the medical insurance organization;

c) the composition of the commission of the territorial CHI fund;

d) regulatory legal acts that are the basis for monitoring the activities of an insurance medical organization for organizing and conducting control and the reasons for conducting control;

e) facts of improper fulfillment by the insurance medical organization of contractual obligations to organize and conduct control, indicating acts of re-examination;

f) the measure of responsibility of the insurance medical organization for the identified violations;

g) applications (copies of acts of re-examination, etc.).

The claim is signed by the director of the territorial CHI fund.

Execution of the claim is carried out within 30 working days from the date of its receipt by the insurance medical organization, about which the territorial CHI fund is informed.

In the event that the territorial CHI fund reveals during the re-examination of violations missed by the insurance medical organization during the medical and economic examination or examination of the ILC, the medical insurance organization loses the right to use the measures applied to the medical organization, due to a defect in medical care that was not detected in a timely manner and / or a violation in case of providing medical care.

Funds in the amount determined by the act of re-examination are returned by the medical organization to the income of the budget of the territorial CHI fund. Sanctions are applied to the insurance medical organization in accordance with the agreement on the financial support of compulsory medical insurance.

The Territorial CHI Fund analyzes the appeals of the insured persons, their representatives and other CHI subjects based on the results of the control carried out by the insurance medical organization.

How is the interaction of subjects of control organized?

Answer. The Territorial Compulsory Medical Insurance Fund coordinates the interaction of subjects of control on the territory of a constituent entity of the Russian Federation, carries out organizational and methodological work that ensures the functioning of control and protection of the rights of insured persons, coordinates the plans for the activities of insurance medical organizations in terms of organizing and conducting control, including plans for inspections by insurance medical organizations medical organizations providing medical care under contracts for the provision and payment of medical care under compulsory medical insurance.

When conducting a medical and economic examination and examination of the ILC, the medical organization provides specialist experts and experts of the ILC within 5 working days after receiving the relevant request, medical, accounting, reporting and other documentation, if necessary, the results of internal and departmental control of the ILC.

In accordance with Part 8 of Article 40 of the Federal Law, a medical organization does not have the right to interfere with the access of specialist experts and experts of the ILC to the materials necessary for conducting a medical and economic examination, an examination of the ILC and is obliged to provide the requested information.

Employees involved in the exercise of control are responsible for the disclosure of confidential information of limited access in accordance with the legislation of the Russian Federation.

Based on Article 42 of the Federal Law, the resolution of disputes and conflicts arising in the course of control between a medical organization and an insurance medical organization is carried out by the territorial CHI fund.

The commission informs the interested parties and the executive authority of the subject of the Russian Federation in the field of healthcare about the results of resolving controversial and conflict issues, about violations in the organization and conduct of control, in the provision of medical care in a medical organization.

How is the accounting and use of control results carried out?

Answer. Reports on the results of the control carried out are provided by insurance medical organizations to the territorial CHI fund. The insurance medical organization and the territorial CHI fund keep records of control acts. Recording documents may be registers of acts of medical and economic control, medical and economic examination and examination of the ILC. The results of the control in the form of acts are transferred to the medical organization within 5 working days. It is possible to conduct electronic document management between the subjects of control using an electronic digital signature.

In the case when the act is delivered to the medical organization personally by a representative of the medical insurance organization / territorial compulsory medical insurance fund, all copies of the act are marked with the date and signature of the recipient. When sending an act by mail, the specified document is sent by registered mail (with an inventory) with notification.

The act can be sent to a medical organization in electronic form if there are guarantees of its reliability (authenticity), protection against unauthorized access and distortion.

The head of the medical organization or the person replacing him considers the act within 15 working days from the date of its receipt.

If the medical organization agrees with the act and measures applied to the medical organization, all copies of the acts are signed by the head of the medical organization, certified by a seal, and one copy is sent to the medical insurance organization / territorial CHI fund.

If the medical organization disagrees with the act, the signed act is returned to the medical insurance organization with a protocol of disagreements.

Based on the analysis of the activities of subjects of control, the Territorial CHI Fund develops proposals that contribute to the improvement of the CMP and the efficiency of the use of CHI resources and informs the executive authority of the constituent entity of the Russian Federation in the field of healthcare and the territorial authority Federal Service on supervision in the field of health and social development.

In accordance with Article 31 of the Federal Law, a claim or lawsuit against a person who has caused harm to the health of the insured person, in order to reimburse the costs of paying for the medical care provided by the medical insurance organization, is carried out on the basis of the results of the examination of the ILC, drawn up by the relevant act.

Is it necessary to inform the insured persons about the identified violations in the provision of medical care under the territorial CHI program?

Answer. Yes need. In order to ensure the rights to receive affordable and high-quality medical care, insured persons are informed by medical organizations, medical insurance organizations, territorial compulsory medical insurance funds about violations in the provision of medical care under the territorial compulsory medical insurance program, including the results of control. Work with citizens' appeals in the Federal Compulsory Medical Insurance Fund, territorial compulsory medical insurance funds and insurance medical organizations is carried out in accordance with the Federal Law of May 2, 2006 N 59-FZ "On the Procedure for Considering Appeals from Citizens of the Russian Federation" and other regulatory legal acts regulating work with citizens' appeals . When an insurance medical organization or a territorial MHI fund receives a complaint from the insured person or his representative about the provision of medical care of inadequate quality, the results of the consideration of the complaint based on the results of the examination of the ILC are sent to his address.

How can a medical organization appeal against the conclusion of an insurance medical organization based on the results of control?

Answer. In accordance with Article 42 of the Federal Law, a medical organization has the right to appeal against the conclusion of an insurance medical organization based on the results of control within 15 working days from the date of receipt of the certificates of an insurance medical organization by sending a claim to the territorial CHI fund according to the recommended sample.

The claim is made in writing and sent along with the necessary materials to the territorial CHI fund. The medical organization is obliged to provide to the territorial CHI fund: a) justification of the claim; b) a list of questions for each disputed case; c) materials of internal and departmental control of the ILC in a medical organization.

The territorial CHI fund, within 30 working days from the date of receipt of the claim, considers the documents received from the medical organization and organizes repeated medical and economic control, medical and economic examination and examination of the ILC, which, in accordance with Part 4 of Article 42 of the Federal Law, are drawn up by the decision of the territorial fund.

The decision of the territorial CHI fund, recognizing the correctness of the medical organization, is the basis for the cancellation (change) of the decision on non-payment, incomplete payment of medical care and / or on the payment of a fine by the medical organization for failure to provide, late provision or provision of medical care of inadequate quality based on the results of primary medical and economic examination and / or examination of the ILC.

The territorial CHI fund sends a decision based on the results of the re-examination to the medical insurance organization and to the medical organization that sent the claim to the territorial CHI fund.

The change in funding based on the results of consideration of disputable cases is carried out by the insurance medical organization no later than 30 working days (during the final settlement with the medical organization for the reporting period).

If the medical organization disagrees with the decision of the territorial fund, it has the right to appeal this decision in court.

Who and how can carry out medical and economic expertise and expertise of the ILC?

Answer. In accordance with Part 5 of Article 40 of the Federal Law, a medical and economic examination is carried out by a specialist expert who is a doctor with at least five years of experience in the medical specialty and who has undergone appropriate training in expert activities in the field of CHI.

The main tasks of the specialist-expert are:

a) monitoring the compliance of the medical care provided with the terms of the contract for the provision and payment of medical care under compulsory medical insurance by establishing the compliance of the actual terms for the provision of medical care, the volume of medical services provided for payment with the records in the primary medical and accounting documentation of the medical organization;

b) participation in the organization and conduct of the examination of the ILC and ensuring guarantees of the rights of insured persons to receive medical care of proper quality.

The main functions of a specialist-expert are:

a) selective control of the volume of medical care for insured events by comparing the actual data on those provided to the insured person medical services with procedures for the provision of medical care and standards of medical care;

b) selection of cases for examination of the ILC and substantiation of the need for its implementation, preparation of documentation necessary for the expert of the ILC to conduct the examination of the ILC;

c) preparation of materials for the methodological base used for the examination of the CMP (procedures for the provision of medical care and standards of medical care, clinical protocols, guidelines, etc.);

d) generalization, analysis of the conclusions prepared by the ILC expert, participation in the preparation of an act of the established form or preparation of an act of the established form;

e) preparation of proposals for filing claims or lawsuits against a medical organization for compensation for harm caused to insured persons, and sanctions applied to a medical organization;

f) familiarization of the management of the medical organization with the results of the medical and economic examination and examination of the ILC;

g) generalization and analysis of control results, preparation of proposals for the implementation of targeted and thematic medical and economic examinations and examinations of the ILC;

h) assessment of the satisfaction of the insured persons with the organization, conditions and quality of the medical care provided.

Examination of the CMP in accordance with Part 7 of Article 40 of the Federal Law is carried out by an expert of the CMP who is a medical specialist with a higher professional education, a certificate of accreditation of a specialist or a certificate of a specialist, at least 10 years of work experience in the relevant medical specialty and trained in expert activities in the field of compulsory medical insurance, included in the territorial register of experts of the ILC.

The expert of the IMC conducts an examination of the IMC in his main medical specialty, determined by a diploma, a certificate of accreditation of a specialist or a certificate of a specialist.

During the examination of the ILC, the expert of the ILC has the right to remain anonymous / confidential.

The main task of the CMP expert is to conduct an expert examination of the CMP in order to identify defects in medical care, including assessing the correctness of the choice of a medical organization, the degree of achievement of the planned result, establishing causal relationships of identified defects in medical care, drawing up an expert opinion and recommendations for improving the CMP in compulsory medical insurance.

The ILC expert is not involved in the examination of the ILC in a medical organization with which he has an employment or other contractual relationship, and is obliged to refuse to conduct an examination of the ILC in cases where the patient is (was) his relative or a patient in whose treatment the ILC expert took part .

Expert of the ILC during the examination of the ILC:

a) uses medical documents containing a description of the treatment and diagnostic process, if necessary, performs an examination of patients;

b) provides information about the used normative documents(procedures for the provision of medical care and standards of medical care, clinical protocols, guidelines) at the request of officials of the medical organization in which the examination of the ILC is carried out;

c) comply with the rules of medical ethics and deontology, keep medical secrets and ensure the safety of loans received for temporary use medical documents and their timely return to the organizer of the examination of the ILC or to a medical organization;

d) during the internal examination, the CMP discusses with the attending physician and the management of the medical organization the preliminary results of the examination of the CMP.

The territorial register of ILC experts contains information about the ILC experts who carry out the examination of the ILC within the framework of control in the constituent entity of the Russian Federation, and is a segment of the unified register of ILC experts.

The maintenance of the territorial register of experts of the ILC is carried out by the territorial funds of compulsory medical insurance in accordance with paragraph 9 of part 7 of Article 34 of the Federal Law on the basis of uniform organizational, methodological, software and technical principles.

Responsibility for violations in the maintenance of the territorial register of ILC experts lies with the director of the territorial CHI fund.

In accordance with clause 11 of part 8 of article 33 of the Federal Law, the Federal Compulsory Medical Insurance Fund conducts single register ILC experts, which is a set of electronic databases of territorial registers of ILC experts.

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