conclusions of a medical insurance organization
based on control results
73. In accordance with article 42 Federal law the medical organization has the right to appeal the conclusion of the medical insurance organization based on the results of the control within 15 working days from the date of receipt of the acts of the medical insurance 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. A 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 of a fine by the medical organization 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 against this decision in court.
XII. Organization by the territorial fund of the obligatory
health insurance control in the implementation
payments for medical assistanceprovided to the insured
persons outside the subject 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 subject Russian Federationin the territory of which the policy of compulsory medical insurance was issued is carried out in accordance with sections III-V of this Procedure.
А13-8280 / 2012
48/2012-117992(1)
ARBITRATION COURT OF VOLOGDA REGION
st. Herzen, 1 "a", Vologda, 160000
In the name of the Russian Federation
DECISION
The operative part of the decision was announced on December 17, 2012
The full text of the decision was made on December 24, 2012
Arbitration court Of the Vologda region, composed of: judges O.I. Lukenyuk while keeping the minutes of the court session by the secretary of the court session Kuklinova Yu.Yu., having considered in open court the case on the claim of the budgetary health care institution of the Vologda region "Vologda city polyclinic No. 2" against the open joint-stock company of the Medical Insurance company "Sheksna-M" on the cancellation of acts of medical and economic expertise No. 100096, No. 100099, No. 100052, No. 100056, No. 100074 and on the collection of 22 313 rubles 64 kopecks,
with the participation of the plaintiff - Zolotova ON. by proxy from 10.01.2012, from the defendant - Pershina E.S. by power of attorney dated 02.08.2012 No. 56-12
u st and about in and l:
the municipal budgetary health care institution "Vologda City Polyclinic No. 2" (OGRN 1053500000267, hereinafter - the Institution, the plaintiff) filed a claim with the Arbitration Court of the Vologda Region with a claim against open Joint Stock Company Medical Insurance Company "Sheksna-M" (OGRN 1023501265402, hereinafter - the Company, the defendant) on recognition illegal and on the abolition of acts of medical and economic expertise No. 100096, No. 100099, No. 100052, No. 100056, No. 100074.
In support of the claim, the plaintiff refers to the violation by the defendant of the procedure for organizing and conducting control of the volumes, terms, quality and conditions for the provision of medical care under compulsory health insuranceestablished by order of the Federal Compulsory Medical Insurance Fund dated 01.12.2010 No. 230.
During the consideration of the case, the plaintiff clarified the name of the Institution - budgetary health care institution of the Vologda region "Vologda city polyclinic №2". The court accepted the clarification of the name.
During the consideration of the case, the plaintiff announced the clarification of the claims, namely: he asks the court to declare illegal and cancel the acts of the medical and economic examination No. 100096, No. 100099, No. 100052, No. 100056, No. 100074 and recover the unjustifiably written off funds in the amount of 22 313 rubles 64 kopecks.
By the court in accordance with Article 49 of the Arbitration procedural code The Russian Federation adopted a clarification of the claims.
At the hearing, the plaintiff's representative supported the amended claims in full on the basis of the arguments set out in the statement of claim and in the statement on clarification of the claim.
The representative of the defendant does not recognize the claims on the basis of the arguments set out in the response to the statement of claim.
After hearing the explanations of the representative of the plaintiff, the defendant, witnesses, examining the case materials and evaluating the evidence collected in the case, the court considers that the claims of the Institution are not subject to satisfaction on the following grounds.
As established by the materials of the case, the Company in February 2012 at the Institution carried out a planned inspection of the organization and control of the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance, the results of which are reflected in the acts of medical and economic examination No. 100099, 100074, 100056 and acts of examination of the quality of medical care No. 100096 and 100052, which were approved by the director of the Vologda branch of OJSC MSK Sheksna-M on February 28, 2012 and agreed by the head physician of the Institution on April 11, 2012. These circumstances are not disputed by the parties.
In accordance with the act of medical and economic examination No. 100099, out of the verified cases of medical care, 20 cases were recognized as containing defects / violations for the amount of 3,016 rubles 61 kopecks; according to the act of medical and economic examination No. 100074, respectively, 176 defects in the amount of 12,450 rubles 88 kopecks; under the act of medical and economic expertise No. 100056 - 18 defects in the amount of 14,748 rubles 81 kopecks; according to the certificate of examination of the quality of medical care No. 100096 - 123 defects in the amount of 25 345 rubles 39 kopecks; according to the certificate of examination of the quality of medical care No. 100052 - 5 defects in the amount of 3,400 rubles 43 kopecks.
The institution did not agree with the results of the audit, which served as the basis for going to court with this statement of claim.
The court established that the relationship between the parties is based on the contract for the provision and payment of medical care under compulsory health insurance No. 74 dated February 22, 2011. Clause 1 of this agreement stipulates that the Institution undertakes to provide the necessary medical assistance to the insured person within the framework of the territorial compulsory health insurance program, and the Company undertakes to pay for the medical care provided in accordance with the territorial compulsory health insurance program. Clause 2.1 of the contract stipulates that the Company undertakes to pay for the provided medical care, taking into account the results of monitoring the volumes, terms, quality and conditions of medical care. At the same time, clause 3.2 of the agreement gives the Company the right not to pay or not fully pay the costs of the Institution for the provision of medical care, as well as to demand a refund if violations of contractual obligations are revealed in relation to the volume, timing, quality and conditions of medical care.
Clause 5.2 of the agreement establishes the right of the Institution to appeal against the conclusion of the Company in the event of disagreements on the results of medical and economic control, medical and economic expertise and expertise of the quality of medical care in the implementation of compulsory medical insurance in the manner prescribed by the legislation of the Russian Federation.
In accordance with clause 2 of Article 40 of the Federal Law "On Compulsory Health Insurance in the Russian Federation" No. 326-FZ dated November 29, 2011 (hereinafter - FZ No. 326 dated November 29, 2011), the volume, timing, quality and conditions of medical care are controlled by medical and economic control, medical and economic examination, examination of the quality of medical care.
By virtue of paragraph 3 of Article 40 of the Federal Law No. 326 dated November 29, 2011, medical and economic control is the establishment of the compliance of information on the volume of medical care provided to insured persons on the basis of the registers of accounts submitted for payment by a medical organization to the terms of contracts for the provision and payment of medical care for compulsory medical insurance, the territorial program of compulsory health insurance, methods of payment for medical care and tariffs for paying for medical care.
The concept of medical and economic expertise is given in paragraph 4 of Article 40 of the Federal Law No. 326 dated November 29, 2011, which includes establishing the correspondence of the actual terms of medical care, the volume of medical services presented for payment to the records in the primary medical documentation and the accounting and reporting documentation of the medical organization.
The examination of the quality of medical care reveals violations in the provision of medical care, including determining the 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 (paragraph 6 of Article 40 of the Federal Law No. 326 of 11/29/2011).
Article 42 of the Federal Law No. 326 of 29.11.2011 regulates the procedure for appealing the conclusions of an insurance medical organization on the assessment of control over the volume, timing, quality and conditions of medical care.
In accordance with paragraph 1 of Article 42 of the Federal Law No. 326 dated November 29, 2011, a medical organization within 15 working days from the date of receipt of acts of an insurance medical organization has the right to appeal the conclusion of an insurance medical organization in the presence of disagreements based on the results of medical and economic control, medical and economic examination and examination the quality of medical care by sending a claim to the territorial fund.
The claim is made in writing and sent along with the necessary materials to the territorial fund. The territorial fund, within 30 working days from the date of receipt of the claim, examines 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 (paragraphs 2 and 3 of Article 42 of the Federal Law No. 326 dated November 29, 2011) ... If the medical organization disagrees with the decision of the territorial fund, it has the right to appeal this decision to judicial procedure.
In accordance with clause 56 of the Procedure for organizing and conducting control of volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance ", approved by order of the Federal Compulsory Health Insurance Fund of December 1, 2010 No. 230 (hereinafter referred to as the Procedure), the results of control in the form acts within 5 working days are transferred by the insurance organization to the medical organization. At the same time, clause 57 of the approved Procedure determines that in the case when the act is delivered to the medical organization personally by the representative of the insurance company, a mark of receipt is put on all copies of the act, indicating the date and signature of the recipient. In accordance with clause 58 of the Procedure, the head of the medical organization considers the act within 15 working days from the date of its receipt and in case of disagreement with the act, the signed act is returned to the medical insurance organization with a protocol of disagreements.
Clause 73 of the Procedure establishes that 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 fund of compulsory medical insurance.
The claim is made in writing and sent along with the necessary materials to the territorial compulsory health insurance fund. A 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.
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 are drawn up by the decision of the territorial fund (paragraph 74 of the Procedure). If the medical organization disagrees with the decision of the territorial fund, it has the right to appeal this decision in court.
After examining and evaluating the evidence presented in the case in accordance with Article 71 of the Arbitration Procedure Code of the Russian Federation, the court concluded that the stated claims were groundless.
The plaintiff did not comply with the requirements of clause 58 of the Procedure, namely: the head of the Institution signed the verification acts, sealed them, while, in case of disagreement with the acts, it was necessary to draw up protocols of disagreements. The acts submitted in the case materials, signed and sealed, testify to the absence of disagreements on the results of the audit at the time of signing the acts by the Institution.
The court cannot agree with the arguments of the plaintiff that the certificates were received on April 11, 2012, since the evidence confirming this fact was not presented to the court. The date of approval of the act cannot serve as proof of receipt of the acts on April 11, 2012. In clarifying the claims, this argument was excluded by the plaintiff. Under such conditions, the court concludes that the acts were delivered to the plaintiff within the time period provided by the established Procedure.
The court finds untenable the plaintiff's arguments that the defect code 4.2 is unreasonably indicated in the acts of medical and economic examination No. 100074 and No. 100056 on the grounds that the defects according to code 4.2 are assessed in the examination of the quality of medical care, and these acts were drawn up based on the results of the medical and economic expertise. In Appendix No. 8 to the approved Procedure, containing a list of grounds for refusing to pay for medical care (reducing payment for medical care), code 4.2 indicates defects in the preparation of primary medical documentation that impede the examination of the quality of medical care (inability to assess the dynamics of the health status of the insured person, the volume, the nature and conditions of the provision of medical care). In the course of the medical and economic examination, the correspondence of the actual terms of the provision of medical care, the volume of medical services presented for payment to the records in the primary medical documentation is established. Considering these circumstances, the court concludes that the indication by the defendant in the above acts of the identified defects under code 4.2 does not contradict the requirements of these rules.
The court established that on 25.04.2012 the plaintiff filed a claim No. 1-3 \\ 353 under Act No. 100096 in the amount of 5,237 rubles 88 kopecks, with a claim No. 1-3 \\ 352 under Act No. 100074 in the amount of 6,558 rubles 39 kopecks and claim No. 1-3 \\ 343 under act No. 100056 in the amount of 10,517 rubles 37 kopecks to the Territorial Fund of Compulsory Health Insurance of the Vologda Region, thereby using its right provided for in paragraph 73 of the Procedure. At the same time, when the Territorial Compulsory Health Insurance Fund of the Vologda Region, by its decision No. 6 of May 17, 2012, refused to consider the submitted claims, the plaintiff did not exercise his right granted to him by clause 76 of the Procedure and did not appeal this decision in court.
In such circumstances, the court considers the plaintiff's claims to be unjustified in law and size and not subject to satisfaction.
According to the rules of Article 110 of the Arbitration Procedure Code of the Russian Federation, in case of refusal to satisfy the claim, the costs of the plaintiff to pay state duty are not refundable.
Guided by Articles 110, 167-171, 176 of the Arbitration Procedure Code of the Russian Federation, the Arbitration Court of the Vologda Region
i decided:
to refuse the budgetary health care institution of the Vologda Oblast “Vologda City Polyclinic No. 2” in satisfying claims against the open joint-stock company of the Medical Insurance Company “Sheksna-M”.
The decision of the court can be appealed to the Fourteenth Arbitration Court of Appeal within one month from the date of its adoption.
Judge O. I. Lukenyuk
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. To avoid unpleasant consequences, in the event of inaccuracy 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 CHI? What is the procedure and terms 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 the contractual relationship 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, administrative penalties and sanctions can be applied in the form of restricting medical practice or reducing funding for services provided. In the event of serious violations, the insurance company may terminate the agreement on further cooperation with the medical institution.
The use of penalties has a negative impact on the reputation of the hospital. 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 providing 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. Legal and regulatory sources regulate the obligations of the insurance fund, which consists in considering the claim and organizing control of the medical institution within 30 days from the date of registration of the incoming document. If the Foundation has not taken any measures during the specified time period, then the medical organization may consider the inaction of the Foundation illegal. Thus, if FFOMS did not transfer 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 the court to extend the appeal period. If the evidence of the Foundation's illegal actions is substantial, the court will decide in favor of the plaintiff.
Appeal procedure
In the event that the head of the 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:
- Sign the expert opinion and acts attached to it;
- Draw up a protocol of disagreement;
- Transfer documents to the insurance company;
- Prepare a set of regulated and recommended documentation justifying the relevance of the claim;
- Make a claim;
- 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, but 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 Compulsory Medical Insurance Fund on participation in the insurance program;
- Cooperation agreement with an insurance company;
- Acts of medical and economic control and examination;
- Certificate of examination of the quality of medical care;
- Documents substantiating or refuting the information reflected in the examination;
- Disagreement protocols.
Procedure for considering claims medical organizations based on the results of the control of the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance, carried out by medical insurance organizations, were approved by orders of the TFOMI for each constituent entity of the Russian Federation.
The article discusses the procedure for appealing the 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 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
↯ More articles in the journal
One of the key elements of interaction between health insurance organizations (hereinafter referred to as the HMO) and medical organizations in the field of compulsory health insurance (hereinafter referred to as the CHI) is the control of the volume and quality of medical care, which is carried out by the HI by means of medical and economic expertise and examination of the quality of medical care (hereinafter - KMP).
Considering that the results of examinations are grounds for applying 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 different ways, including the creation of conciliation commissions, arbitration courts.
Since the entry into force of the Federal Law of November 29, 2010 No. 326-FZ "On Compulsory Health Insurance in the Russian Federation" (hereinafter - Law No. 326-FZ), medical organizations have the right to appeal the conclusion of the Medical Insurance Organization based on the results of control by sending a claim to the territorial cHI fund (hereinafter - TFOMS).
The procedure for appealing the conclusions of the HMO based on the results of control is regulated (see the document in the ES "Economics of Medical 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 providing medical care for compulsory health insurance, approved by order of the FFOMS dated 01.12.2010 No. 230 (hereinafter - the Procedure).
In accordance with the specified normative legal documents, an appeal against the conclusions of the medical organization based on the results of the control is carried out by a medical organization by sending a claim to the 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 the TFOMS the materials of internal and departmental control of the 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 disputable 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 TFOMS of St. Petersburg
In 2013, the TFOMS of St. Petersburg received 159 claims from 39 medical organizations for 872 cases of expert examinations, which were carried out by eight medical organizations.
The total number of contested cases of expert examinations in comparison with 2012 increased 4.2 times, 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 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%), conducted 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 significantly change compared to 2012 (48 and 52% of examinations, respectively). The results of medical and economic examinations carried out by the medical and health care organizations were contested mainly by adult hospitals and outpatient clinics (hereinafter referred to as AAP) (60.2 and 30.1% of cases, respectively), the results of examinations of the CMO 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 resolved 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 specialists-experts of the TFOMS of St. Petersburg; for 432 cases (60%), a re-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<…>