The article discusses the procedure for appealing conclusions based on the results of control of medical insurance organizations and the results of implementation given right medical organizations in St. Petersburg.

The article discusses the procedure for appealing conclusions based on the results of control of medical insurance organizations and the results of the exercise of this right by medical organizations in St. Petersburg.

The procedure for appealing the conclusions of medical insurance organizations

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One of the key elements of interaction between medical insurance organizations (hereinafter referred to as HMS) and medical organizations in the field of compulsory health insurance (hereinafter referred to as MHI) is the control of volumes and quality. medical care, which is carried out by the medical and economic examination and examination of the quality of medical care (hereinafter - KMP).

Considering that the results of examinations are grounds for the application of financial sanctions, they inevitably become the cause of disagreements between medical organizations and medical organizations. The resolution of these disagreements until 2010 was carried out in the regions of the Russian Federation in various ways, including the creation of conciliation commissions, arbitration courts.

Since the entry into force of the Federal Law of 29.11.2010 No. 326-FZ "On compulsory health insurance in Russian Federation»(Hereinafter - Law No. 326-FZ) medical organizations have the right to appeal the conclusion of the medical insurance system based on the results of control by sending a claim to the territorial CHI fund (hereinafter - TFOMI).

The procedure for appealing the conclusions of the HIO based on the results of control is regulated (see the document in the ES "Economics of Health Care Facilities" -)<…>Art. 42 of Law No. 326-FZ and section XI of the Procedure for organizing and monitoring the volume, timing, quality and conditions of the provision of medical care for compulsory health insurance, approved by order of FFOMS dated 01.12.2010 No. 230 (hereinafter referred to as the Procedure).

In accordance with the specified regulatory legal documents the appeal of the conclusions of the CMO based on the results of the control is carried out medical organization by sending a claim to TFOMS within 15 working days from the date of receipt of the examination certificate (medical and economic or ILC examination).

Together with the claim, the medical organization sends to TFOMS materials of internal and departmental control ILC, protocols of disagreements and other materials that may contribute to the resolution of the dispute.

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 examinations and examinations of the ILC, the results of which in accordance with Part 4 of Art. 42 of Law No. 326-FZ are formalized by the decision of the TFOMS.

The decision of the TFOMS is sent to the medical organization and the medical organization, in accordance with it, the medical organization changes the financing of disputed cases no later than 30 working days (during the period of final settlement with the medical organization for the reporting period). If a medical organization disagrees with the decision of the TFOMI, it has the right to appeal this decision in court.

Results of appeal by medical organizations of expert opinions of medical insurance organizations to the TFOMS of St. Petersburg

In 2013, the TFOMS of St. Petersburg received 159 claims from 39 medical organizations on 872 cases of expert examinations, which were carried out by eight medical organizations.

The total number of contested cases of expert examinations increased by 4.2 times compared to 2012, while the largest number of claims still came from medical organizations providing inpatient medical care to the adult population (hereinafter referred to as adult hospitals) - 75.3 and 80 % of cases, respectively (Table 1).

The total number of medical organizations that filed claims in 2013 compared to 2012 increased by 1.7 times. In 2013, the contested cases included the conclusions of the CMO based on the results of 352 medical and economic examinations (40.4%) and 520 examinations of the ILC (59.6%), carried out by ILC experts from the territorial register of ILC experts in St. Petersburg (hereinafter - registry).

The ratio of the disputed results of medical and economic examinations and examinations of the ILC did not change significantly compared to 2012 (48 and 52% of examinations, respectively). The results of the medical and economic examinations carried out by the Medical and Health Organization were contested mainly by adult hospitals and outpatient clinics (hereinafter referred to as APU) (60.2 and 30.1% of cases, respectively), the results of examinations of the CMU were mainly contested by adult hospitals (85.6% of cases) (Table 2).

In 2013, out of 872 contested cases, 37 cases (4%) were not accepted for consideration by the TFOMI due to violations of the procedure for sending them (deadlines for sending, claim form); 140 cases (16%) did not require expert action and were settled through oral and written explanations by the TFOMI; 695 disputable cases (80%) were accepted for consideration in accordance with the established procedure.

In 263 cases (40%), a repeated medical and economic examination was carried out by experts from the TFOMS of St. Petersburg; in 432 cases (60%), a repeated examination of the ILC was organized with the involvement of 32 ILC experts included in the register.

Repeated medical and economic examinations<…>

Repeated examinations of the quality of medical care<…>

The result of the quality control of medical services is a formalized expert opinion, which reflects the identified shortcomings in the service of insured persons and prescribes recommendations for their elimination. If the expert noted gross violations, then sanctions and fines may be imposed on the institution, which will certainly negatively affect its reputation. In order to avoid unpleasant consequences, in case of unreliability of the data reflected in the examination, the head of the medical institution can initiate an appeal against the event.

Who and why can demand an appeal against the results / conclusions of the examination of the quality of medical care under the compulsory medical insurance? What is the procedure and time frame for appeal? What documents will be needed for this and how is the claim made? What can be the result of the appeal? We will answer these questions in this article.

Reason for appealing the results of the examination

Quality control of the services provided, including such parameters as terms, volumes and conditions regulated by the rules of the insurance program and contractual relations between the parties, is carried out in accordance with the Order of the Federal Fund No. 230 dated 01.12.2010. New requirements for assessing the quality of medical care are reflected in the Order of the Ministry of Health No. 520n dated 15.07.2016.

After the completion of expert work in the field of quality control of the provided medical services, the head medical institution an expert opinion on the event is transmitted. The document states all the facts of the considered case of consultative or medical assistance, and also indicates the shortcomings identified during the investigation. In addition to recommendations for the further conduct of activities, can be applied administrative penalties and sanctions in the form of restricting medical practice or reducing funding for services provided. When malicious violations, the insurance company may terminate the agreement on further cooperation with the medical institution.

The use of penalties has negative impact on the reputation of a medical institution. Therefore, if the head of a hospital or polyclinic has the opportunity to justify their actions, or to refute the claims made in the expert opinion, they seek to initiate an appeal procedure in order to maintain their rating in the market for the provision of medical services under the insurance program.

Deadline for filing a claim

Within 15 days from the date of receipt of the expert opinion, medical institution has the right to appeal against its results. If the claim is sent for consideration by the representatives of the Fund later than this period, it will be rejected. Regulatory sources regulate responsibilities insurance fund, consisting in the consideration of the claim and the organization of control of the medical institution within 30 days from the date of registration incoming document... If the Foundation has not taken any measures during the specified time period, then the medical organization may consider the Foundation's inaction to be illegal. Thus, if the FFOMS has not transferred to the institution all Required documents to appeal the results of the EKMP within the prescribed period (seized during the inspection), then the healthcare facility may apply to judicial instance to extend the appeal period. If the evidence misconduct Fund will be weighty, then the court will decide in favor of the plaintiff.

Appeal procedure

If the head of a medical institution does not agree with the results of the examination and can document his innocence, he should act in accordance with the algorithm regulated by regulatory sources:

1. Sign the expert opinion and acts attached to it;
2. Draw up a protocol of disagreement;
3. Transfer documents to insurance company;
4. Prepare a set of regulated and recommended documentation substantiating the relevance of the claim;
5. Make a claim;
6. Send a claim with a set of documents to the territorial fund within the prescribed period.

There are no requirements regulating the form and template of the claim to the medical aid examination act, however, it must contain information identifying the addressee and the applicant. In the application, you must indicate the subject that was the reason for the appeal, as well as the essence of the document and the purpose of its preparation. Signature, date of writing the paper and a list of documentation to it as an attachment are required.

To dispute the results of the examination of the quality of medical care, it is necessary to file a claim and prepare a set of documentation. The information content of the documents should substantiate the complaint about the survey results. The documentary package includes:

• Registration and authorization papers confirming the legality of the activities of the medical institution;
• Agreement with the Mandatory Medical Insurance Fund on participation in the insurance program;
• Cooperation agreement with an insurance company;
• Acts of medical and economic control and examination;
• The certificate of examination of the quality of medical care;
• Documents substantiating or refuting the information reflected in the examination;
• Disagreement protocols.

The procedure for considering claims of medical organizations based on the results of the control of the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance, carried out by medical insurance organizations, was approved by orders of the TFOMI for each constituent entity of the Russian Federation.

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FFOMS ORDER of 01-12-2010 230 ON APPROVAL OF THE ORGANIZATION ORGANIZATION AND CONTROL OF QUALITY TERMS AND CONDITIONS ... Actual in 2018

XI. Appeal by a medical organization of the conclusion of an insurance medical organization based on the results of control

The claim is made in writing and is sent along with the necessary materials to the territorial fund of compulsory health insurance. The medical organization is obliged to provide to the territorial compulsory health insurance fund:

a) substantiation of the claim;

b) a list of questions for each contested case;

c) materials of internal and departmental quality control of medical care in a medical organization.

74. The territorial fund of compulsory medical insurance, 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 quality of medical care, which, in accordance with Part 4 of Article 42 of the Federal of the law are formalized by the decision of the territorial fund.

75. The decision of the territorial fund of compulsory medical insurance, 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 primary medical and economic examination and / or examination of the quality of medical care.

Changes in funding based on the results of consideration of disputed cases are carried out by an insurance medical organization no later than 30 working days (during the period of final settlement with a medical organization for the reporting period).

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

conclusions of a medical insurance organization

based on control results

73. In accordance with article 42 of the Federal Law, a medical organization has the right to appeal the conclusion of an insurance medical organization based on the results of control within 15 working days from the date of receipt of acts of an insurance medical organization by sending a claim to the territorial compulsory medical insurance fund according to the recommended model (Appendix 9 to this Procedure).

The claim is made in writing and sent along with the necessary materials to the territorial compulsory health insurance fund. The medical organization is obliged to provide to the territorial compulsory health insurance fund:

a) substantiation of the claim;

b) a list of questions for each contested case;

c) materials of internal and departmental quality control of medical care in a medical organization.

74. The territorial fund of compulsory medical insurance, 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 quality of medical care, which, in accordance with Part 4 of Article 42 of the Federal Law issued by the decision of the territorial fund.

75. 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 primary medical and economic examination and / or examination of the quality of medical care.

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

(the paragraph was introduced by the Order of FFOMS dated 16.08.2011 N 144)

Changes in funding based on the results of consideration of disputed cases are carried out by an insurance medical organization no later than 30 working days (during the period of final settlement with a medical organization for the reporting period).

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

XII. Organization by the territorial fund of the obligatory

health insurance control in the implementation

payments for medical care provided to the insured

persons outside the constituent entity of the Russian Federation,

in the territory of which a policy of compulsory

health insurance

77. Organization of control by the territorial fund of compulsory medical insurance when making payments for medical care provided to insured persons outside the constituent entity of the Russian Federation, on the territory of which the policy of compulsory medical insurance was issued, is carried out in accordance with sections III-V of this Procedure.