07.07.2017

Compensate for material damage associated with insurance claims medical companies to the work of the Seversk Central District Hospital, they decided to withhold the lost amounts from the salaries of doctors. This was reported by Yugopolis with reference to the independent media outlet of the Seversky district, Narodnaya Gazeta.

As is known, in Russia there is government system compulsory health insurance (CHI). Free medical care that citizens receive in healthcare institutions is paid to hospitals and clinics insurance organizations, working in compulsory medical insurance system. But they have the right to control the work of medical institutions. And if they identify violations in the quality or execution of services provided to the patient, the insurance company can “punish” the hospital with penalties. The reasons for imposing penalties may be incorrect preparation of medical documentation (for example, spelling, syntax errors or unclear handwriting), non-compliance with procedures and standards of medical care. Insurers actively use this mechanism.

According to the document at the disposal of Narodnaya Gazeta (Minutes No. 7 of the meeting of the medical commission based on the results of internal control of the quality and safety of medical activities dated July 25, 2016, chaired by the head physician of the Seversk Central District Hospital M.A. Ananikov), the amount of fines of medical insurance companies in the amount RUR 2,595,414.02 it was decided to compensate at the expense of “doctors responsible for economic losses and causing material damage to the institution” - “in the form of deprivation of incentive payments, as well as other payments not provided for employment contracts workers up to full repayment material damage caused to the employer."

The list of those “at fault” includes 58 doctors. Two gynecologists at the Seversk Central District Hospital must pay more than 26 thousand rubles each; two local therapists - 62 and 71 thousand rubles; three more local therapists - 232, 223 and 188 thousand rubles. respectively.

According to the newspaper, the head physician of the Seversk Central District Hospital and his deputies, who are responsible for the work of doctors and the quality of medical services they provide, are not on the list of employees from whose salaries are subject to deduction.

According to the “fined” doctors, no one at the Central District Hospital notified them about the “sanctions”, and many found out about them only when they signed their payroll. Those who became indignant were told: remain silent or you will never receive any bonuses at all.

Seversky lawyer Sergei Bogdanov considers deductions from doctors’ salaries illegal.

At the request of Narodnaya Gazeta, the head of the regional hospital commented on the situation with the deprivation of payments to doctors in the Seversk Central District Hospital. public organization“Right to health” Nikolay Chernyshuk:

Different medical institutions deal with fines differently. Someone is trying to reach an agreement with the insurance company, someone is introducing an internal review of medical records, someone is defending illegal fines in court. But if sanctions do occur, the administration often resolves the issue at the expense of its employees. You need to understand that the total amount of money received by a doctor consists of several components - salary, tariff rate, additional incentives and compensation payments. The first two parameters are quite difficult to change, and they are fixed. Compensation payments, according to the law, is also difficult to change - this is only possible if working conditions change. Another thing is incentive payments, which, in essence, are the good will of the employer, the so-called bonuses; by law they are at least 30%. The hospital budget has a certain amount of money for incentive payments, which is distributed among all team members depending on a joint decision, with the participation of the administration, representatives of the trade union, and representatives of the workforce. In practice, the manager usually personally decides who should be paid extra and how much, and who should not, which is a mechanism of influence on doctors.

According to Nikolai Chernyshuk, the “punished” medical workers of the Seversk Central District Hospital have every reason to appeal the actions of the hospital management.

The editors of Narodnaya Gazeta announced their intention to transfer the documents at its disposal, indicating the “punishments” of doctors of the Seversk Central District Hospital, to the prosecutor’s office with a request to conduct an investigation.

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Most read

The new order of the Ministry of Health on compulsory medical insurance will lead to an increase in unreasonable fines

A year ago, ONF activists turned to Roszdravnadzor with a request to restore order with fines in the compulsory medical insurance system, but the situation still remains the same

Experts from the Independent Monitoring Foundation “Health” analyzed the order of the Ministry of Health on changes to the rules of compulsory medical insurance and believe that new order calculating sanctions for medical organizations will lead to unreasonable fines and underpayment for quality medical care. Among other things, fines are provided for failure of doctors to comply with approved standards medical care, however, ONF experts have questions about the standards themselves.

One of the important innovations of the registered order of the Ministry of Health No. 536n was the establishment of a procedure for calculating sanctions applied to medical organizations. This document amends the current rules of compulsory health insurance.

“By law, the quality of medical care is controlled, inter alia, on the basis of compliance with standards. But it is impossible not to violate these standards adopted by the Ministry of Health! It seems that they were deliberately poorly developed and approved with errors, so that insurance companies would constantly “cut off” money from medical organizations,” said Eduard Gavrilov, a member of the ONF Central Headquarters, Director of the Health Foundation.

For example, the standards for treating many diseases in a hospital require mandatory provision Wasserman reaction, although more modern tests have long been used instead, for example, the nonspecific antiphospholipid (reagin) test. Standards of care for systemic sclerosis, heart transplant, or nosebleeds require patients of any age to see a pediatrician.

“According to the standard of infertility treatment, patients are prescribed to see a gynecologist in 100% of cases, i.e. persons of both sexes! All this would be funny if doctors were not fined for failure to comply with these requirements,” noted Eduard Gavrilov.

The Fund notes that by issuing such orders, the Ministry of Health does not protect medical organizations and doctors from the arbitrariness of insurance companies. It is the latter who will benefit most from the order. They are interested in increasing the volume of sanctions because they keep part of the collected money as profit. A year ago, ONF activists appealed to Roszdravnadzor with a request to restore order with fines, but the situation still remains the same.

Information provided by the press service of the All-Russian Popular Front

Image from the website polisoms.rf

According to the results of inspections in 2013, it turned out that insurance companies withheld about 50 billion rubles from medical organizations - almost 4% of the annual federal budget. compulsory medical insurance fund. A significant part of these funds “settled” in the companies themselves. In the coming years, the amounts that insurers will be able to keep for themselves “to conduct business” will become even greater, experts warn: due to the transition to single-channel financing, the bulk of the money will go to healthcare through territorial compulsory medical insurance funds and insurance companies. At the same time, insurers do not defend the rights of patients in any way, but are focused “on identifying paper flaws in the work of doctors.”

Where does the profit come from?

Experts from the Independent Monitoring Foundation “Health” have calculated what share of the budget for compulsory health insurance “settles” in insurance companies. “According to our experts, up to 4% of these funds remain in medical insurance organizations in the form of deductions, write-offs, and fines from medical institutions. This is about 50 billion rubles,” said Eduard Gavrilov, director of the Health Foundation. He recalled that, according to the law, medical insurance organizations in the field of compulsory medical insurance not only receive a budget for conducting business, but also make a profit. It consists of money that hospitals and clinics “unreasonably presented for payment” (insurers receive up to 30% of these amounts), fines for medical care not provided or provided late, as well as medical care of inadequate quality (insurance companies take up to half of these fines) and “ savings" (from which insurers receive 10%).

According to Gavrilov, all control measures, as well as assessment of the quality of medical care, should be carried out only by government bodies, and not “profit organizations living off funds allocated for free healthcare for citizens.” Moreover, already next year, due to the transition to single-channel financing, the bulk of funds will begin to flow into healthcare through territorial compulsory medical insurance funds and insurance companies. And if, in 2013, the total budget of the Fund compulsory medical insurance was about 1 trillion rubles, then in 2015 it will grow to 1.4 trillion rubles.

“Today, a huge flow of money has flowed into healthcare through territorial compulsory medical insurance funds and medical insurance organizations, and the amounts that insurers, by law, can keep for themselves “to conduct business” are becoming gigantic,” Gavrilov believes. Moreover, these “cases” sometimes look very peculiar: one of the insurance organizations last year purchased 22 tennis tables, and also paid its employees for the services of a massage therapist using unconventional methods of treatment.

The Federal Compulsory Medical Insurance Fund, in response to a request from Mednovosti, clarified that insurance companies did not have all the money withheld from hospitals, but only a part. “Based on the results of inspections in 2013, medical insurance organizations withheld about 50 billion rubles from medical organizations. At the same time, according to the legislation on the formation own funds 1.7 billion rubles were allocated from funds unreasonably presented for payment by medical organizations, identified during an examination of the quality of medical care, and funds received as a result of payment of fines by medical organizations for the provision of medical care of inadequate quality. The remaining funds in the amount of 48.3 billion rubles were returned to the territorial compulsory medical insurance funds and were again used to pay for medical care in medical organizations,” the FFOMS reported.

For comparison, 1.7 billion rubles is a quarter of the budget of the territorial compulsory medical insurance fund of a small Russian region (for example, in the Kaluga region in 2013 it was 7.5 billion rubles). And we are talking only about “premium” ones. According to the Health Foundation, Russian medical insurance organizations (61 in total) received 24 billion rubles from the budget in 2013 directly for business management.

No patients needed

At the same time, as doctors say, insurance company employees are not interested in the results of treatment. Premiums and salaries of insurers depend only on the number of flaws they find in the documents filled out by doctors. “Insurers especially like to come with checks in the spring, before the summer - in order to receive good bonuses for the holidays,” said a doctor at one of the clinics in Lipetsk. - The believers take a few cards selectively and start digging. Either the analysis is not confirmed, or after the analysis there is no description and treatment is prescribed without taking this analysis into account. It's just written illegibly. But when there’s a huge line of patients outside the door and a bunch of paperwork needs to be filled out, there’s no time for calligraphy. And you can’t prove that you looked at this analysis.”

“Everyone is afraid to contact insurance companies; it is absolutely impossible to challenge their sanctions,” adds a local pediatrician from the Moscow region. - I had a case when a mother brought her child for an examination after visiting the dentist. On the same day they had an appointment with an ophthalmologist. As a result, the inspectors left the service only to the dentist, the ophthalmologist and I were crossed out, and even fined, accusing us of making additions. Even the intervention of this child’s mother did not help.” According to her, the situation is no better in hospitals, where doctors are fined for “overexposure” of patients. As a result, patients are not left in the department a single day longer than expected, even if they get worse. Moreover, as the doctor explained, doctors urgently remove patients from a dangerous state and then discharge them. “If a person becomes ill on the day of discharge, he will be taken out of this state and discharged anyway,” said MedNews’ interlocutor. “I witnessed the scene when relatives came to pick up my grandmother from the hospital and waited until the evening while they cleaned her up. The patient experienced a glycemic coma, but the manager. department (by the way, a very competent endocrinologist) categorically refused to leave her until the morning, fearing fines.”

According to the consultant of the Open Institute of Population Health, professor at the Higher School of Economics, Doctor of Medical Sciences. Kirill Danishevsky, there is nothing surprising in the behavior of insurance companies, because the goal of any commercial organization- Receiving a profit. And the audits carried out in hospitals are legal: the insurance company has the right to know what it paid for. What’s worse is that fines from medical institutions become an end in themselves, and no one thinks about the interests of the patient. “Patients don’t even know that they received actually defective medical care,” the expert explained to Mednovosti. -- Insurance Company Based on the documentation remaining after treatment, he concludes that the patient received poor-quality care, fines the hospital, and does not consider it necessary to inform the patient about this. It’s not like we should compensate him for something or give him additional examination and treatment.”

“At the moment, experts from insurance companies check (on paper) the compliance of medical care with approved standards, as well as the justification for the provision of a particular service,” says Danishevsky. - Simply put, the medical documentation should show the compliance of the treatment with the data of the examination. But filling out documentation is not a medical service, and the quality of its completion is not the quality of treatment. Moreover, as you know, a third, or even half, of the doctor’s appointment time is spent on paperwork.” According to the expert, she Russian system health insurance “is artificial.” “By their nature, insurers must compete with each other, choose medical institutions, and negotiate with them,” he says. “We don’t have anything like that, and therefore there is no opportunity to boost the quality of work of institutions.”

The President of the Society of Evidence-Based Medicine, Vasily Vlasov, also does not consider the activities of Russian insurance companies to be real insurance. “These companies do not raise money and do not pay insurance cases, the expert explained to Copper News. - They receive money from the territorial compulsory medical insurance fund and pay for the work of medical organizations, while keeping part of the funds. That is, the state uses a private intermediary to transfer public money to public hospitals. Many people do not understand this system. Therefore, some say that insurance organizations should be made state-owned, while others say that they are not needed at all. I am one of those who believe that these companies should be abolished and the work of government agencies should be paid for without intermediaries.”

However, according to the president of the non-profit foundation “Supporting the welfare and health of the nation “Assistance””, Doctor of Law. Vsevolod Sazonov, the situation could be corrected using less radical methods, by establishing real control over the activities of the insurance organizations themselves. According to him, although the Rules of Compulsory Medical Insurance establish a procedure for the disclosure by insurance organizations of information about financial results their activities, this is no longer enough. “It is necessary to establish clear controls and supervision over this activity at the legislative level,” says Sazonov.

But despite the difference in approaches, all experts agree on one thing: the current operating system of insurance companies is no good. It “eats up” a considerable part of the budget, but at the same time it complicates the lives of doctors and does not help patients in any way.

Irina Reznik

Comments (25)

27.11.2014 11:42

DoctorNorth

Before the New Year, they will again go to hospitals to collect for Thailand

27.11.2014 12:29

It’s time to put an end to these insurance companies making money out of thin air (actually stealing the country and medicine, in particular). Tighten penalties for corruption, as in China (for the conspiracy of a group of people to harm the state by stealing funds, ultimately causing harm to the health of the people as a result of curtailing programs (ex. oncology). This is the so-called planned mortality due to failure to provide medical care (no drugs , childbirth in SP cars due to the destruction of unprofitable maternity hospitals (sanitary aviation does not fly for childbirth).According to Lenin - red terror to white terror, otherwise we will lose our country and people!

27.11.2014 13:20

Doctor

Alas, that's all true!!! I don’t want to work in a hospital because of this nonsense!

27.11.2014 14:22

Doctor A.S.

“According to the results of inspections in 2013, it turned out” - somehow “suddenly” it turned out... I have known this since the 90s.

27.11.2014 15:11

Man from compulsory medical insurance

Custom-made material for the purpose of discrediting insurers.

27.11.2014 16:02

Ivan

It is necessary to eliminate commercial insurance organizations and switch to non-profit ones, as in Germany. So that the money goes not to shareholders, but back to the healthcare sector. And what needs to be checked is not how the doctor fills out the paperwork, but the quality of the medical care provided.

27.11.2014 17:39

Guest

What is insurance? When you buy compulsory motor liability insurance, you get the opportunity to compensate for your losses for a certain amount. Not a penny more! I took CASCO insurance - the amount is different, the conditions are different. What is the point of health insurance? No one finds out how much you actually contributed to the insurance fund, and whether you contributed at all. Help is provided according to standards. This simple system distribution of money. And weaning too. Isn’t it easier to distribute them “personally” or some other way? We would be better off in terms of the number of square kilometers in the region. And return to clear and transparent “rates” for health workers. Without any incentives or anything.

27.11.2014 20:31

Lonelyowl

Insurers demand treatment and examination “according to standards,” and they did not care about the words of our minister that “standards are not for treatment, but for planning.” There are simply no standards as such, as a result, these “great doctors” in insurance companies, who have never even cured anyone’s runny nose in their lives, have invented a bunch of their own standards, which they demand compliance with. From what point these “standards” are based, no one knows. Complete nonsense; but if you don’t do it, they’ll fuck you. These farriers have no idea about an individual approach.

28.11.2014 00:05

Reader

Where can I get acquainted with these standards for 2014-2015?

28.11.2014 00:08

Guest

Why these intermediaries at all?
A lot of money is spent on offices, employees, profits, etc.
Those who work there are often those who were asked to come from medicine, because they are not good as doctors.
But they felt like bosses, whom everyone was afraid of, otherwise they would kill them.
What is the point of their work? Cut up the state ones, i.e. our money?
Voluntary insurance is clear here.
What about the state one? What is the raison d'être for these companies?

28.11.2014 06:35

Endosurgeon

Guest
They have been robbing us for 20 years, and you just have a question - why are they needed? This is obvious, they were immediately invented to steal. “Insurance is theft,” this is the rhyme of the former Minister of Health Shevchenko, after which he quietly disappeared from the horizon.

28.11.2014 07:18

Doctor

To the reader
Officials of various stripes are very fond of talking about standards and protocols, but no one has ever seen them in real life and who knows where you will find them.

28.11.2014 17:26

Ivan

@Guest


28.11.2014 17:27

Ivan

@Guest
We don’t know why we have them. In a working system, insurance companies check the quality of care provided and help the patient receive compensation for damage if any was caused to the patient. He also advises the patient about the possibility of receiving medical care (Where, what kind, rehabilitation options, spa treatment). Dedicated to promoting a healthy lifestyle.

From the editor:

Fines and other sanctions in the compulsory health insurance system can seriously complicate the life of healthcare institutions. Practice shows that these sanctions are not always justified. This is what the proposed material is devoted to. We hope this material will be useful for healthcare institutions and, perhaps, will serve as a basis for improvement. regulatory framework compulsory health insurance.

Chief editor N.G. Kurakova

PENALTY AND OTHER SANCTIONS IN THE COMPLIANCE INDUSTRY SYSTEM AND METHODS TO COUNTER THEM

CONSULTED BY D.Sc. F.N. KADYROV

In accordance with Part 8 of Article 39 of the Federal Law of November 29, 2010 No. 326-FZ “On Compulsory Medical Insurance in Russian Federation"(hereinafter referred to as the Federal Law on Compulsory Medical Insurance) for failure to provide, untimely provision or provision of medical care of inadequate quality under a contract for the provision and payment of medical care under mandatory health insurance the medical organization pays a fine in the manner and amount established by the contract for the provision and payment of medical care under compulsory health insurance.

A number of paragraphs of the Order of the Federal Compulsory Health Insurance Fund dated December 1, 2010 No. 230 “On approval of the procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance” (hereinafter referred to as Order No. 230) are devoted to fines.

/ Manager 1\Р1

\health 3013*

Regarding the implementation of Order No. 230, there is a Letter from the Federal Compulsory Health Insurance Fund dated March 15, 2011 No. 1257/30-4/i “On the implementation of the Compulsory Medical Insurance Order No. 230 dated December 1, 2010” (hereinafter referred to as the Compulsory Medical Insurance Letter).

Territorial compulsory medical insurance funds and medical insurance organizations, in accordance with clause 8 of part 7 of article 34 and clause 2 of part 3 of article 39 of the Federal Law on Compulsory Medical Insurance, monitor the volume, timing, quality and conditions of medical care provided by medical organizations within the framework of compulsory medical programs insurance.

The results of the monitoring of the volumes, timing, quality and conditions of medical care are documented in acts that include information about identified violations and appropriate sanctions. The forms of acts of medical and economic control, medical and economic examination and examination of the quality of medical care, as well as the List of grounds for refusal to pay for medical care (reduction of payment for medical care) were approved by the Compulsory Medical Insurance Fund Order No. 230.

In accordance with Article 41 of the Federal Law on Compulsory Medical Insurance, the amount that is not payable based on the results of monitoring the volumes, timing, quality and conditions of providing medical care is withheld from the amount of funds provided for payment for the medical care provided by the medical organization, or is subject to return to the medical insurance organization in in accordance with the contract for the provision and payment of medical care under compulsory health insurance and the List of grounds for refusing to pay for medical care or reducing payment for medical care. Mutual obligations of medical organizations and medical insurance organizations, the consequence of non-fulfillment of which is application to the parties

appropriate measures are provided for by the agreement concluded between them for the provision and payment of medical care under compulsory health insurance.

The standard form of an agreement 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 No. 1184n (clause 7) provides for the liability of a medical organization in accordance with Articles 39 and 41 of the Federal Law on Compulsory Medical Insurance.

A possible list of obligations of a medical organization and the consequences of their non-fulfillment, entailing the possibility of non-payment or incomplete payment of the costs of providing medical care, as well as payment by the medical organization of a fine (hereinafter - penalties and other sanctions) for failure to provide, untimely provision or provision of medical care of inadequate quality, is attached to the MHIF Letter under consideration.

An analysis of these obligations shows that not every failure to fulfill obligations can serve as a basis for the application of appropriate penalties and other sanctions.

Let's look at this in more detail.

Clause 1.1.1 of Order No. 230 and the MHIF Letter defines the obligation of a medical organization to ensure the selection of a medical organization from medical organizations participating in the implementation of the territorial program, in accordance with the application of the insured person.

Does this mean that in any case where a medical organization does not provide the insured with this right, penalties immediately follow? Of course not.

Firstly, the insured may mistakenly contact an institution that does not provide the corresponding type of medical care at all.

Secondly, one should distinguish between concepts such as justified and unjustified

Manager

refusal. Refusal to provide a choice of medical organization may be justified.

Thirdly, a situation may arise when there are no grounds for applying fines and other sanctions due to the fact that there is no regulatory framework necessary for their implementation.

Thus, in accordance with clause 4) part 1 of article 16 of the Federal Law on Compulsory Medical Insurance, insured persons have the right to choose a medical organization from medical organizations participating in the implementation of the territorial compulsory health insurance program in accordance with the legislation of the Russian Federation.

What kind of legislation is this? This is the Federal Law of the Russian Federation dated November 21, 2011 No. 323 “On the fundamentals of protecting the health of citizens in the Russian Federation.” Article 21 of this Federal Law is precisely devoted to the choice of a doctor and a medical organization. Citizens have the right to choose a medical organization in the manner approved by the authorized federal body executive power. At the moment, there is no corresponding order from the Russian Ministry of Health and Social Development. Consequently, before the relevant order is issued, there is no way to assess whether the rights of the insured in this part have been violated or not. Therefore, there are no grounds for applying penalties or other sanctions.

But even when the appropriate procedure appears, not any action or inaction of a medical organization that does not provide the opportunity to choose can be considered guilty. For example, if an insured person, in order to receive specialized medical care in a planned form, tries to independently choose a medical organization, and not on the direction of the attending physician, as provided for in Part 4 of Article 21 of the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, refusal

by the relevant medical organization cannot be considered a violation.

A similar situation arises with regard to the right of citizens to choose a doctor. Clause 1.1.2 of Order No. 230 and the MHIF Letter provides for such an obligation as ensuring the choice of a doctor in accordance with the application of the insured person submitted personally or through his representative addressed to the head of the medical organization.

In accordance with clause 5 of part 1 of Article 16 of the Federal Law on Compulsory Medical Insurance, insured persons have the right to choose a doctor by submitting an application personally or through their representative addressed to the head of the medical organization in accordance with the legislation of the Russian Federation. But again, in accordance with Article 21 of the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation,” which provides, in particular, that the choice is made taking into account the consent of the doctor.

Clause 1.1.3. Order No. 230 and the MHIF Letter provide for the obligation of a medical organization to comply with the conditions for the provision of medical care, including waiting periods for medical care provided as planned.

Part 4 of Article 21 of the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” establishes that if in the implementation of the territorial program state guarantees Several medical organizations are involved in providing free medical care to citizens, providing medical care in the relevant profile; the attending physician is obliged to inform the citizen about the possibility of choosing a medical organization, taking into account the fulfillment of the conditions for the provision of medical care established by the territorial program of state guarantees of free provision of medical care to citizens. Therefore, if a citizen was informed but ignored this information and

insists on receiving medical care in an organization whose queue exceeds the time limits established by the territorial program of state guarantees of free medical care to citizens, this institution is not to blame for violating the waiting time for medical care by this citizen. Therefore, penalties and other sanctions should not be applied to this medical organization.

Clause 1.2 of Order No. 230 and the MHIF Letter concerns such an obligation of a medical organization as providing medical care to insured persons in accordance with the territorial compulsory medical insurance program. For an unjustified refusal to provide medical care to an insured person, fines and other sanctions are applied.

Could the refusal be justified? Maybe! For example, this may concern the provision of routine medical care. In accordance with clause 3) part 4 of article 32 of the Federal Law “On the fundamentals of protecting the health of citizens in the Russian Federation”, planned medical care is medical care that is provided during preventive measures, for diseases and conditions that are not accompanied by a threat to the patient’s life, not requiring emergency and emergency medical care, and delaying the provision of which for a certain time will not entail a deterioration in the patient’s condition or a threat to his life and health. Therefore, in some cases, planned care for the insured person may be postponed. For example, planned hospitalization may be denied within a previously agreed upon time frame due to the failure of the insured citizen to fulfill the duties assigned to them. Thus, paragraph 1 of part 2 of article 16 of the Federal Law on Compulsory Medical Insurance establishes that insured persons are required to present a compulsory health insurance policy when seeking medical care, with the exception of cases of emergency

no medical care. Therefore, a medical organization can reasonably postpone the timing of planned hospitalization until the insured person presents insurance policy. It should be especially noted that this is not a deprivation of the insured person’s right to free medical care, but only a postponement of the provision of planned medical care.

Paragraph 1.2 of Order No. 230 and the MHIF Letter is devoted to preventing the collection of fees from insured persons (as part of voluntary health insurance or in the form of paid services) for medical care provided under the territorial program.

Does this mean that you cannot take money at all for medical services provided for by the territorial compulsory medical insurance program? No, it doesn't mean that. Federal law“On the fundamentals of protecting the health of citizens in the Russian Federation” provides for situations in which medical organizations have the right to provide paid services and by types of assistance included in compulsory medical insurance programs. In accordance with Part 5 of Article 84 of this Federal Law, medical organizations participating in the implementation of the Program of state guarantees of free provision of medical care to citizens and the territorial program of state guarantees of free provision of medical care to citizens have the right to provide paid medical services to patients on conditions other than those provided for by the Program of state guarantees of free provision of medical care to citizens, territorial programs of state guarantees of free provision of medical care to citizens and (or) targeted programs; when providing medical services anonymously, except for cases provided for by the legislation of the Russian Federation, etc.

In addition, in accordance with Part 2 of Article 19 of the Federal Law “On the Basis

Manager

Vakh protection of the health of citizens in the Russian Federation" everyone has the right to receive paid medical services and other services, including in accordance with a voluntary medical insurance agreement. In accordance with Part 1 of Article 84 of this Federal Law, citizens have the right to receive paid medical services provided at their request when providing medical care, and paid non-medical services (household, service, transport and other services) provided additionally when providing medical care. Therefore, citizens can exercise the right to receive not free, but paid medical care. And the medical organization has no right to deprive them of this right. This federal law (like any other) has greater force compared to orders (and even more so letters) of the Compulsory Medical Insurance Fund. Therefore, penalties and other sanctions can only be applied in cases of violation of the requirements of the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” and/or the resolution of the Government of the Russian Federation, which must be adopted in order to implement this federal law.

Clause 5.3.2 of Order No. 230 and the MHIF Letter concerns the situation of a medical organization presenting for payment cases of medical care in excess of the distributed volume established by the decision of the Commission (we are talking about the Commission for the development of a territorial compulsory health insurance program).

Indeed, in accordance with subparagraph 5) of paragraph 9 of the Procedure for organizing and monitoring the volumes, timing, quality and conditions of providing medical care under compulsory health insurance, approved by Order No. 230, it is envisaged to check that a medical organization does not exceed the volumes of medical care established by the decision of the Development Commission

territorial compulsory health insurance program, to be paid from compulsory health insurance funds.

However, firstly, clarification is required: what volume has been exceeded - is it really established by the Commission for the development of the territorial compulsory health insurance program? And has a new agreement been concluded in accordance with the Order of the Ministry of Health and Social Development of Russia dated December 24, 2010 No. 1184n “On approval of the form standard contract for the provision and payment of medical care under compulsory health insurance?

The fact is that, in accordance with Part 1 of Article 39 of the Federal Law on Compulsory Medical Insurance, an agreement for the provision and payment of medical care under compulsory health insurance is concluded between a medical organization included in the register of medical organizations that participate in the implementation of the territorial compulsory health insurance program and by which decision The commission for the development of the territorial compulsory health insurance program established the volume of medical care to be paid for from compulsory health insurance funds, and the medical insurance organization participating in the implementation of the territorial compulsory health insurance program, in the manner established by this federal law.

If the Commission has not established the specified volume (or the Commission has not yet been created, or the planned volume of assistance has been established by another body), and also if the previous agreement is in force, then the medical insurance organization cannot refer to Order No. 230 and apply appropriate penalties and other sanctions.

Secondly, even if there are all grounds for applying Order No. 230, you must contact the insurance company.

tion and, if necessary, to the territorial compulsory health insurance fund with a reasoned request for payment for volumes of medical care exceeding the volumes established by the Commission.

According to clause 2.9 of the Model Agreement on the financial support of compulsory medical insurance for 2011, approved by Order of the Ministry of Health and Social Development of Russia dated December 24, 2010 No. 1185n “On approval of the form of the standard agreement on the financial support of compulsory health insurance for 2011”, “The medical insurance organization undertakes carry out the formation and replenishment of a reserve reserve to compensate for the excess of expenses for payment of medical services over the funds intended for these purposes, from funds received from the territorial fund according to per capita differentiated standards in accordance with this agreement.” That is, the medical insurance organization must have funds for these purposes. Or she must apply for the necessary funds to the territorial fund.

And the territorial fund has the right in accordance with clause 5.1. the said agreement make a decision on providing the medical insurance organization with funds from the rationed amount that are missing to pay for medical care safety stock territorial fund in case of exceeding the volumes of funds established for a medical insurance organization to pay for medical care due to increased morbidity, an increase in tariffs, an increase in the number of insured persons and (or) a change in their gender and age structure after an audit within ten working days from the date of the medical insurance organizations.

Moreover, paragraph 2) of part 7 of article 34 of Federal Law No. 326-FZ establishes that the territorial fund accumulates

establishes and manages compulsory health insurance funds, provides financial support for the implementation of territorial compulsory health insurance programs in the constituent entities of the Russian Federation, forms and uses reserves to ensure financial stability compulsory health insurance in the manner established by the Federal Fund.

The list of similar situations, when the application of penalties and other sanctions is far from obvious, can be continued.

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

The claim is made in writing and sent along with the necessary materials to the territorial fund.

Territorial fund within 30 working days from the date of receipt of the claim, it reviews the materials received from the medical organization and organizes repeated medical and economic control, medical and economic examination and examination of the quality of medical care.

In accordance with paragraph 75 of Order No. 230, the decision of the territorial compulsory medical insurance fund, recognizing the correctness of the medical organization, is the basis for canceling (changing) the decision on non-payment, incomplete payment of medical care and/or payment by the medical organization of a fine for failure to provide, untimely provision or provision of medical care of inadequate quality based on the results of a primary medical and economic examination and/or examination of the quality of medical care.

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

As we see, healthcare institutions have the opportunity to assert their rights in the event of unlawful application of fines and other sanctions. And you need to be able to use them correctly.

In conclusion, we note that legislators realized that they “went too far” with fines and other sanctions. Part 9 of Article 39 of the Federal Law on Compulsory Medical Insurance provided that for the use of funds transferred to it under an agreement for the provision and payment of medical care under compulsory health insurance by a medical organization for other than its intended purpose, the medical organization shall pay a fine in the amount of the misuse of funds and a penalty in the amount one three hundredth of the refinancing rate Central Bank of the Russian Federation, in force on the day the sanctions were imposed, from the amount of misuse of these funds. The medical organization returns funds used for other than their intended purpose to the budget of the territorial fund within 10 working days from the date the territorial fund submits the corresponding request.

In accordance with the Federal Law of November 30, 2011 No. 369-F3 “On Amendments to the Federal Law “On Obligatory

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compulsory medical insurance in the Russian Federation”, this part is formulated somewhat differently: for the use of funds transferred to it by a medical organization for purposes other than its intended purpose under an agreement for the provision and payment of medical care under compulsory medical insurance, the medical organization pays to the budget of the territorial fund a fine in the amount 10% of the amount of misuse of funds and penalties in the amount of one three hundredth of the refinancing rate of the Central Bank of the Russian Federation in effect on the day the sanctions were imposed, of the amount of misuse of these funds for each day of delay. The medical organization returns funds used for other than their intended purpose to the budget of the territorial fund within 10 working days from the date the territorial fund submits the corresponding request.

That is, the fine became 10 times less.

The following should also be kept in mind. Such consequences of failure to fulfill obligations by medical organizations, such as an amount not payable, a reduction in payment, compensation, do not mean automatic losses for the institution. If these are typos, errors, etc., then you need to correct the relevant documents and issue the account registers again. Unfortunately, healthcare institutions lose a lot of money on invoices that would need to be corrected and issued again.

According to WHO forecasts:

By 2050, the number of diagnosed hip fractures will increase to 6.5 million per year;

By 2025, the number of people with diabetes will be 300 million, up from 177 million in 2011;

By 2020, the number of annually registered cancer cases will increase by 5 million;

By 2020, the shortage of nurses in EU countries will be 2 million people.

According to Federal Law No. 326 FZ, medical organizations are obliged to:

Provide medical care to insured persons within the framework of compulsory medical insurance programs for free. Keep individual records of information about medical care provided to insured persons in accordance with the current Federal Law. Medical organizations are required to provide insurance organizations and the territorial fund with information about the insured person. Give information about the services provided to him medical services necessary to monitor the volume, quality, timing and conditions of medical care. The duties also include the provision of reporting on activities in the field of compulsory health insurance, in the manner established by the Federal Fund and in the appropriate forms. Health care delivery organizations must appropriately utilize targeted programmatic funding. Use compulsory health insurance funds received for medical care provided in full compliance with compulsory health insurance programs. Organizations are obliged to inform the population about the procedures for providing medical care. Post on your official website on the Internet information about operating hours and types of medical care provided. Must provide insured persons, medical insurance organizations and the territorial fund with information about operating hours, types of medical care provided, indicators of accessibility and quality of medical care. Perform other duties in accordance with this Federal Law.<6>

Medical organizations enter into contracts for the provision and payment of medical care under compulsory health insurance. Providing medical care in within the compulsory medical insurance. Part 2 of Art. 39 of the Law on Compulsory Medical Insurance establishes that under an agreement for the provision and payment of medical care under compulsory health insurance, a medical organization undertakes to provide medical care to the insured person within the framework of the territorial compulsory health insurance program, and the insurance medical organization undertakes to pay for medical care provided in accordance with the territorial program compulsory health insurance.

Providing medical care of appropriate quality. Based on the provisions of Part 1 of Art. 16, paragraph 10, part 2, art. 38 and parts 8 of Art. 39 of the Law on Compulsory Medical Insurance, a medical organization is obliged to provide medical care of adequate quality, and only in this case is such care subject to payment.

The procedure for applying economic measures to medical institutions provides for penalties. A list of sanctions applied in a particular case of non-fulfillment or improper fulfillment of one’s obligations is being developed Federal Fund as a supervisory control body. The amount of the penalty depends on the severity of the violation and its consequences. The composition of the violation is determined by conducting a medical and economic examination. After the expert has drawn up a report, the information is transferred to the Territorial Fund, where a decision is made on the application or non-application of the measure and its size. In some cases, penalties against an organization are accompanied by cases separated into separate criminal proceedings that provide for personal liability.

A methodology has been developed for determining the amount of penalties for medical organizations. The size of the financial support standard for the territorial compulsory health insurance program per one insured person in the current year is taken as a constant value.

• 1) The amount not subject to payment based on the results of medical and economic control, medical and economic examination, examination of the quality of medical care is withheld from the amount of funds provided for payment for medical care provided by medical organizations, or is subject to return to the medical insurance organization in accordance with the contract for the provision and payment of medical care under compulsory health insurance, a list of grounds for refusing to pay for medical care or reducing payment for medical care in accordance with the procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care.
• 2) Mutual obligations of medical organizations and medical insurance organizations, the consequence of which is the possibility of non-payment or incomplete payment of the costs of providing medical care, as well as payment by a medical organization of a fine for failure to provide, untimely provision or provision of medical care of inadequate quality, are provided for in the agreement concluded between them for the provision and payment for medical care under compulsory health insurance and the procedure for paying for medical care under compulsory health insurance established by the rules of compulsory health insurance.
• 3) Non-payment or incomplete payment for medical care, as well as payment by a medical organization of fines for failure to provide, untimely provision or provision of medical care of inadequate quality does not exempt the medical organization from compensating the insured person for harm caused through the fault of the medical organization, in the manner established by the legislation of the Russian Federation.
• 4) The provisions of the Law require a health care institution to spend cash Compulsory medical insurance to pay for medical care for the intended purpose. For violation of these norms, the organization pays a fine in the amount of 10% of the amount of misuse of compulsory medical insurance funds and a penalty in the amount of 1/300 of the Bank of Russia refinancing rate in effect on the day the sanctions were imposed for each day of delay.