Ministry of Health of the Kirov Region. Monitoring the volumes, timing, quality and conditions of providing medical care under compulsory health insurance Monitoring the implementation of volumes of medical care
The healthcare system of the Stavropol Territory has a developed network that provides the population with timely and high-quality medical care. Today, there are 130 medical organizations of various organizational, legal forms and forms of ownership operating in the region’s compulsory health insurance system.
Planning of volumes of medical care and financial and economic justification for the size of the per capita standard of financial support for 2015 was carried out taking into account the standards for the volume of medical care by type, conditions and forms of medical care, in accordance with the Territorial Program of State Guarantees for the free provision of medical care to citizens in the Stavropol Territory for 2015 and the planning period of 2016 and 2017, approved by Decree of the Government of the Stavropol Territory of December 25, 2014 No. 542-p.
The results of the implementation of the Territorial Compulsory Health Insurance Program for the 1st half of 2015 have been summed up.
The planned volumes of medical care for the 1st half of 2015 amounted to 10 billion 581 million rubles in the region as a whole.
By type of institution, planned funding was as follows:
regional medical organizations - 2 billion 177 million rubles or 21%;
city medical organizations - 4 billion 974 million rubles or 47%;
central district hospitals - 3 billion 430 million rubles or 32%.
The amount of invoices issued for payment according to medical insurance organizations for the 1st half of 2015 amounted to 10 billion 956 million rubles or 104%.
The amount of accepted invoices for payment according to the CMO for the 1st half of 2015 as a whole amounted to: in total for the region 10 billion 287 million rubles or 97%:
regional medical organizations - 2 billion 033 million rubles or 93%;
city medical organizations - 4 billion 783 million rubles or 96%;
central district hospitals - 3 billion 471 million rubles, or 101%.
In connection with the appeal of medical organizations on issues of increasing the volume of medical care and financial support for 2015, the audit and analytical department of the Federal Compulsory Medical Insurance Fund of the UK carried out analytical work on the results of the implementation in the 1st half of 2015 of the planned volumes of medical care at the Andropov Central District Hospital, Novoselitsk Central District Hospital, Neftekumsk Central District Hospital, Krasnogvardeyskaya Central District Hospital, as well as all primary vascular departments of the region, based on information obtained during inspections, as well as information obtained from the personalized accounting database. The purpose of the audit was to identify the main problems in the performance of medical organizations that resulted in insufficient financial support in 2015.
A structural analysis of the economic losses of the above-mentioned medical organizations due to non-payment of registers of invoices was carried out based on the results of medical and economic control, medical and economic examination, and examination of the quality of medical care carried out by the Federal Compulsory Compulsory Medical Insurance Fund of the UK and medical insurance organizations. The above economic losses are irreversible for most medical organizations due to expired rebilling deadlines.
The main causes of economic losses are:
ineffective planning of financial and economic activities;
defects in planning the volume of medical care;
cases of unnecessary hospitalization;
defects in the preparation of primary medical documentation identified during examinations;
violations in the preparation of account registers;
presence of interrupted treatment cases;
irrational spending of compulsory medical insurance funds.
In the region as a whole, the amount of non-payment of registers of accounts by insurance companies amounted to 670 million rubles.
For example:
Izobilnenskaya Central District Hospital - according to the results of the first half of 2015, the total amount of non-payment of bills for actually completed volumes amounted to 30 million 132 thousand rubles;
Children's Hospital of Philippi - 27 million 493 thousand rubles;
Krasnogvardeyskaya Central District Hospital - non-payment without taking into account overbilled volumes amounted to 14 million 443 thousand rubles;
Neftekumskaya Central District Hospital - the amount of non-payment at the end of the first half of 2015 amounted to 16 million 122 thousand rubles;
Novoselitskaya Central District Hospital - according to the results of the first half of 2015, the total amount of non-payment amounted to 8 million 847 thousand rubles.
Despite the implementation of a number of measures aimed at structural transformations of the system for providing specialized medical care, the development of hospital-replacing technologies, improving the provision of outpatient care to the population, a comparative analysis of the volume of medical care provided in inpatient and day hospital settings indicates that there remains a fairly significant volume of inpatient medical care.
At the same time, inpatient medical care consumes most of the financial resources of the compulsory medical insurance system. Therefore, a necessary condition for the effective development of the industry is not only improving the structure of medical care provided to the population, but also improving the methods of payment using those that, by providing medical organizations with the necessary financial resources, will encourage them to use modern medical technologies and improve treatment methods.
The 24-hour hospital in 2015 operates on 258 DRGs, the planned volumes were agreed upon jointly with the participation of the heads of medical organizations, the Ministry of Health of the region and the Federal Compulsory Medical Insurance Fund of the UK at the conciliation commission on December 16, 2014. But despite this, the results of the first half of 2015 in the context of medical organizations show us that not all organizations provide medical care in accordance with the planned volumes, that is, there is ineffective planning in the context of DRGs and, as a consequence, economic losses and insufficiency financial support.
So, for the 24-hour hospital as a whole, the implementation of the planned number of hospitalizations for 2015 based on the results of the first half of 2015 amounted to 52%.
As a result of a structural analysis of the implementation of the planned volumes of medical care for 2015 in 68 medical organizations with a 24-hour hospital, the following performance indicators are noted at the end of the first half of 2015:
Full compliance of the planned volume indicators of medical care for 2015 with those implemented during the analyzed period for a 24-hour hospital is demonstrated by 5 medical organizations, which is 7% of all that have a 24-hour hospital in their structure: Apanasenkovskaya Central District Hospital, Trunovskaya Central District Hospital, City Clinical Hospital No. 3 of Stavropol, Kraevoy Oncological Dispensary and Regional Uroandrological Center;
implementation of the annual plan is less than 50% registered in 25 medical organizations or 37%;
38 medical organizations or 56% exceeded planned indicators by over 50%.
A structural analysis was carried out in the context of clinical and statistical groups in terms of the effectiveness of planning and execution of state assignments both in terms of volumetric performance indicators and in terms of financial execution of the plan in the context of medical insurance organizations.
A structural analysis of the volumes of medical care provided in a 24-hour hospital in the context of the DRG showed the following. The fulfillment of the annual plan for hospitalizations in the region as a whole of less than 50% was noted by 138 DRGs with a plan of 216 thousand 215 cases in the amount of 4 billion 525 million rubles. actual execution amounted to 75 thousand 357 cases in the amount of 1 billion 380 million rubles. Estimated economic losses for the first half of 2015 amounted to 3 billion 144 million rubles, which indicates ineffective planning of the volume of medical care.
The following DRGs are especially noteworthy:
“Intestinal operations (level 3)”, in which, with a plan of 1447 cases, only 78 were performed, which is 5%;
“Diabetes mellitus without complications, adults” - with a plan of 4,856 cases, only 408 or 8% were completed;
“Infections of the skin and subcutaneous tissue” - with a plan of 3,657 cases, only 299 or 8% were completed;
“Cerebral infarction, treatment with thrombolytic therapy” - with a plan of 870 cases, only 58 or 7% were completed;
“Unstable angina, myocardial infarction, pulmonary embolism, treatment with thrombolytic therapy” - with a plan of 1,380 cases, only 98 or 7% were completed;
“Angina (except unstable), chronic ischemic heart disease, coronary angiography was performed” with a plan of 1,024 cases, 112 or 11% were performed.
First of all, this concerns PSO and RSC, and such a percentage of the planned volumes of medical care for clinical and statistical groups of diseases of the circulatory system, which are one of the main causes of premature mortality and disability of the population, is of concern.
The implementation of the plan for hospitalizations of more than 50% according to 106 DRGs is noted, and the percentage of implementation varies from 51 to 3,638%.
Significant overfulfillment of the plan was noted for the following DRGs:
“Operations on the organ of hearing, paranasal sinuses and upper respiratory tract (cost level 2) with a plan of 813 cases, 2315 or 284% were performed. When analyzing the overfulfillment of volume indicators for this DRG in the context of the municipality, it is noted that in the regional children's clinical hospital of Stavropol 151 cases were planned, 555 cases or 367% were performed, in the city children's clinical hospital named after Philippsky of Stavropol - the above operations were not planned, completed – 396.
The maximum excess of planned indicators was noted according to the DRG “Angioedema, anaphylactic shock” - with the plan there were 8 cases, 291 or 3637% were completed. Overfulfillment of volumes for this DRG was registered in almost all municipalities.
The excess of funding due to exceeding the planned target according to the CSG amounted to 1 billion 880 million rubles.
For example, due to ineffective planning and lack of adjustment of the planned target based on the results of the first half of 2015 for a 24-hour hospital, the estimated economic losses due to failure to fulfill the planned volumes are:
In the Andropovskaya Central District Hospital, due to failure to fulfill the planned volumes for 64 CSGs, the estimated economic losses amounted to 9 million 450 thousand rubles;
in the Novoselitskaya Central District Hospital - 8 million 214 thousand rubles;
In the Neftekumsk Central District Hospital - 3 million 502 thousand rubles.
At the same time, in these medical organizations, for numerous DRGs, there is a significant excess of the annual plan both in terms of volume and financial indicators.
Thus, in the Neftekumsk Central District Hospital, the implementation of the annual plan by more than 50% was revealed by 60 DRGs. With a planned cost of 56 million 679 thousand rubles for the year, 39 million 848 thousand rubles were actually paid, which is 70.3% of the annual plan;
in the Novoselitskaya Central District Hospital there is an excess of planned volumes for 35 CSG. The planned cost for 2015 according to the specified CSG is 11 million 564 thousand rubles, in fact, payment was made in the amount of 13 million 354 thousand rubles, that is, the annual plan for 6 months according to financial indicators was fulfilled by 115.5%;
in the Andropov Central District Hospital, the planned volumes for 2015 for 42 CSGs were exceeded. The planned cost of these DRGs is 30 million 816 thousand rubles, the actual payment was 21 million 508 thousand rubles, that is, the annual plan for financial indicators was fulfilled by 69.8%.
Based on the analysis, we can conclude that adjustments to the planned target for the volume of medical care in a 24-hour hospital are not made by medical organizations and, accordingly, the planned financing as a whole is distorted.
Activities of day hospitals
Despite the implementation of a number of measures aimed at structural transformations of the system of specialized medical care and the development of hospital-replacement technologies, the situation is as follows. Based on the results of the 1st half of 2015, the planned indicators for the provision of medical care in day hospitals in the Stavropol Territory were fulfilled by 47%.
The compliance of the completed volumes of medical care with the planned ones was noted only in 4 medical organizations: “Departmental hospital of Russian Railways in Mineralnye Vody”, “Arzgir Central District Hospital”, “City Clinic No. 1” in Nevinnomyssk, “Nevinnomyssk Treatment and Rehabilitation Center”.
Implementation of less than 50% - in 52 municipalities, of which in 16 central district hospitals, 31 city hospitals and 5 regional institutions;
Exceeded the approved indicators by over 50% - 34 medical organizations, of which 9 central district hospitals, 20 city municipalities and 5 regional ones.
A comparative analysis of the performance results of day hospitals in the context of DRGs revealed the implementation of the plan for hospitalizations of less than 50% for 71 DRGs with a plan of 97,469 cases in the amount of 1 billion 203 million rubles. actual execution amounted to 37,329 cases amounting to 484 million rubles. Estimated economic losses for the 1st half of 2015 amounted to 718 million rubles, which indicates ineffective planning of the volume of medical care.
In addition, a striking example of ineffective planning for a day hospital in terms of significantly exceeding the planned target is the volume of assistance provided according to 19 DRGs, where the percentage of fulfillment varies from 100 to 4200%.
The most indicative are the fulfillment of volumes for the following DRGs:
“Diabetes mellitus with complications, adults”, 102 cases planned for the year, 273 or 277% completed.
“Diseases of the pancreas”, 287 cases planned for the year, 571 or 199% completed.
“Pneumonia, pleurisy, other pleural diseases”, 96 cases were planned for the year, 124 or 129% were completed.
“Chemotherapy for other malignant neoplasms of lymphoid and hematopoietic tissues, adults”, 13 cases planned, 94 or 723% completed.
“Liver diseases, level 2”, 2 cases planned, 84 or 4200% completed!!
And there are many such examples!
At the same time, the day hospital plan is adjusted by medical organizations in isolated cases. Using the example of the same medical organizations, we note the facts of ineffective planning in day hospitals, and as a result, the discrepancy between the actually completed volumes of medical care in a day hospital in the context of the DRG and the financial fulfillment of the state task for 2015:
in the Andropov Central District Hospital, the financial fulfillment of the day hospital plan for the first half of 2015 due to non-fulfillment of volumes (according to personalized accounting) amounted to 38%. Estimated economic losses due to failure to fulfill planned volumes amounted to 1 million 679 thousand rubles based on the results of the first half of 2015;
In the Krasnogvardeyskaya Central District Hospital, the plan for the day hospital as a whole was fulfilled by 60%, which in the total amount of actually paid invoice registers amounts to 15 million 942 thousand rubles. The planned cost of all DRGs for 2015 for day hospitals is 26 million 044 thousand rubles. Based on this, the excess funding in the first half of 2015 due to overfulfillment of volumes amounted to 2 million 920 thousand rubles;
In the Neftekumskaya Central District Hospital for day hospitals as a whole, according to the results of the first half of 2015, the plan was fulfilled by 57%, which in the total amount of actually paid accounts registers amounts to 11 million 139 thousand rubles. The planned cost of all DRGs for a day hospital is 10 million 166 thousand rubles. Based on this, the excess funding due to overfulfillment of volumes amounted to 973 thousand rubles;
Ineffective planning of DRGs and implementation of volumes of medical care for unplanned DRGs was revealed, which led, accordingly, to non-compliance with the planned volumes of financial support for 2015.
In the Neftekumskaya Central District Hospital, the implementation of volumes of medical care for unplanned DRGs was identified in 21 DRGs, where 127 patients were treated for a total amount of 1 million 842 thousand rubles. Medical insurance organizations have requested medical histories to check the validity of hospitalizations in a 24-hour hospital. The results of the examination upon completion of the work will be communicated to interested parties.
And such planning defects are inherent in almost all medical organizations!
We conducted a structural analysis of interrupted cases of treatment in a 24-hour hospital. As a result, it was revealed that in the Stavropol Territory as a whole, in the compulsory health insurance system, economic losses due to interrupted cases of treatment for the first half of 2015 amounted to 328 million rubles;
Economic losses by type of institution were as follows:
In central district hospitals - 82 million rubles;
In medical organizations located in the cities of the region - 198 million rubles;
In regional medical organizations - 48 million rubles.
The main reasons for interrupted cases are:
death of the patient, which is 10% of the total number of interrupted cases of treatment,
transfer to another medical organization - 25%,
discharge for reasons beyond the control of the Ministry of Defense - 65%.
A structural analysis of interrupted cases of treatment of patients in a 24-hour hospital showed that the proportion of patients discharged for reasons beyond the control of the Ministry of Defense for the first half of 2015 was 65%.
Patients discharged for reasons beyond the control of the medical organization are divided into the following categories:
treatment was interrupted at the patient’s initiative – 46%;
treatment was interrupted at the initiative of the medical organization – 9%;
treatment was interrupted due to transfer to a day hospital – 2%;
treatment was interrupted due to transfer to another profile of bed capacity – 20%;
unauthorized patient care – 23%.
To reduce the volume of economic losses due to preventable causes, medical organizations should pay attention to the main problems of interrupted treatment cases:
patient-initiated discharge;
unauthorized departure of the patient;
non-compliance with the prescribed regimen, drug therapy;
technical errors when creating registers-accounts: incorrect filling in the fields of registers-accounts, technical errors made during the implementation of the software product in medical organizations.
TFOMS UK recommends that heads of medical organizations take measures to eliminate preventable causes of interrupted cases. To reduce the number of interrupted cases for reasons of “discharge on the initiative of the patient” and “unauthorized care,” it is necessary to carry out educational work with patients, since in most cases, premature discharge of patients leads to re-hospitalization. We also propose to strengthen control over patients in 24-hour and day hospitals by nursing and junior medical staff to eliminate reasons for discharge such as violation of the regime and unauthorized care.
To eliminate technical errors when issuing registers-invoices, TFOMS UK invites you to bring the conditions for issuing registers-invoices in medical organizations in accordance with the requirements of the Tariff Agreement and pay especially close attention to Article 39 “Rules for payment of interrupted cases of treatment in inpatient conditions and in day hospitals” and table 10 “List of DRGs, payment for ultra-short cases of medical care attributed to which is carried out at the DRG tariff, regardless of the actual stay of the patient,” since most of the interrupted cases in the billing registers belong to this list.
An analysis was carried out of the functioning of the unified information resource (or EIR263), through which data is exchanged when organizing information support for insured persons in the context of medical organizations and bed profiles for the reliability and timely updating of information on the functioning of bed capacity in a 24-hour hospital. As a result of the analysis, it was revealed that the share of unjustified emergency hospitalization in the total number of patients hospitalized in a 24-hour hospital varies from 20% to 30%, depending on the level and profile of medical organizations.
Most medical organizations do not update data in a timely manner or do not enter patient discharge data into the EIR263 software resource at all.
Starting from July 2014 and throughout the current year, TFOMS SK has repeatedly sent letters of recommendation and organizational nature to the heads of the Moscow Region on the functioning of the EIR263 software resource, but despite this, defects in the organization of the work of Moscow Region operators in the software complex have not been eliminated.
Contact details of the Ministry of Defense are not filled out in 50% of organizations, despite comments and clarifications, for example, in Petrovskaya Central District Hospital, Kochubeevskaya Central District Hospital, Stavropol Emergency Hospital, Arzgir Central District Hospital, Grachevskaya Central District Hospital, Andropovskaya Central District Hospital.
Data on the discharge of patients is not entered in a timely manner at the Stavropol Emergency Hospital (3,587 patients were not discharged), Novoselitsk Central District Hospital (874 patients were not discharged), and the Regional Perinatal Center (625 patients were not discharged), and accordingly the number of patients exceeds the number of beds necessary to fulfill the state task.
Monitoring of the implementation of planned volume indicators of the territorial compulsory medical insurance program for the 1st half of 2015 was carried out in the context of all areas of outpatient services.
Outpatient medical care is provided in 117 medical organizations in the region operating in the compulsory medical insurance system, including 99 medical organizations and 18 dental clinics.
In general, the volume of visits to the region was completed by 102% of the plan for the 1st half of 2015, including 94% in connection with the disease, 124% for preventive purposes and 70% for emergency medical care.
Including services to the child population, the volume of visits in the region was completed at 110% of the plan for the 1st half of 2015 (including 95% in connection with illness, 133% for preventive purposes and 66% for emergency medical care).
The fulfillment by medical organizations of the region of planned volume indicators in terms of visits in connection with the disease amounted to 97% of the year's plan for the region as a whole, including 96% for the child population.
For a significant number of medical organizations, the failure to fulfill the plan for visits in connection with the disease is due to the overfulfillment of planned volume indicators for visits for preventive purposes.
Most medical organizations receive requests for illness by calculation, which is unacceptable. We draw your attention to the fact that it is necessary to keep separate records of “calls regarding illnesses” and not to allow distortions of the actual volumes by type of visits.
The fulfillment by medical organizations of the region of planned volumetric indicators in terms of visits for preventive purposes amounted to 124% in the region as a whole, and 133% for the child population. The main reasons for this increase in preventive visits are: lack of organization in recording visits, discrepancy between planned volumes and those actually completed, incorrect application of tariffs and, as a consequence, distortion of the planned target.
In order to increase the efficiency of timely identification of risk factors for diseases and the organization of their correction, as well as early diagnosis of diseases that most determine the disability and mortality of the population of the region, medical organizations of the region conduct medical examinations of the population.
Clinical examination of the adult population in 2015 is planned in the Stavropol Territory in the amount of 500 thousand112 people. Based on the results of the activities of 49 medical organizations, 254 thousand 280 people underwent medical examination, which is 51% of the annual plan.
Fulfillment of the annual plan below 30% was noted in the “City Clinic No. 1” in Pyatigorsk, the “Ipatovskaya Central District Hospital”, and the “City Clinic” in Essentuki.
Preventive examinations of the adult population of the region are planned for 2015 in the amount of 90 thousand 970 people. During the first half of 2015, 30 thousand 322 people underwent preventive medical examinations, which is 33% in the region. A low percentage of implementation was noted in the “City Clinic No. 1” of Pyatigorsk, “Andropovskaya Central District Hospital”, “Ipatovskaya Central District Hospital”.
Medical examination of orphans and children in difficult life situations staying in inpatient institutions, as well as orphans and children left without parental care, including adopted children, taken under guardianship, in foster care or foster care family in 2015 in the Stavropol Territory is subject to the plan of 6 thousand 966 people. Over the past 6 months of 2015, 2 thousand 745 cases were accepted for payment for medical examinations, which is 39% of the annual plan.
Fulfillment of the annual plan 0%!!! noted in the “Alexandrovskaya Central District Hospital”, “Budennovskaya Central District Hospital”, “Neftekumskaya Central District Hospital”, “Novoselitskaya Central District Hospital”. The main reason, according to the Ministry of Defense, is planning the volume of medical examinations for the autumn period in connection with the beginning of the school year. For preventive medical examinations of minors, 213 thousand 575 people are planned for 2015. In the first half of 2015, 92 thousand 944 cases were accepted for payment for preventive medical examinations of minors, which is 44%.
Fulfillment of the annual plan 0%!!! noted in the “Neftekumskaya Central District Hospital” and in the “Novoselitskaya Central District Hospital” due to the lack of specialists.
For periodic medical examinations of minors, 119 thousand 872 people are planned for 2015. During the first half of 2015, 23 thousand 074 people underwent periodic medical examinations of minors, which is 19% of the region as a whole.
Fulfillment of the annual plan 0%!!! noted in the “Neftekumskaya Central District Hospital”, “Novoselitskaya Central District Hospital”, “Petrovskaya Central District Hospital”, “Blagadenenskaya Central District Hospital”, “Andropovskaya Central District Hospital”.
The fulfillment by medical organizations of the region of planned volume indicators in terms of visits for emergency medical care amounted to 70% in the region as a whole, including 66% for the child population.
The main reason for non-fulfillment of the plan for emergency medical care is due to the fact that medical institutions of the region often charge for the provision of emergency medical care to patients as a case of a one-time visit by the patient to a medical organization in connection with an illness, or include it in the tariff for treatment and thereby choosing more high payment for a completed case.
For emergency medical care in the Stavropol Territory, in accordance with the approved task, the planned volume indicators for 2015 were fulfilled for the first half of 2015 by 50%.
While the plan was 814 thousand 674 calls, the actual number was 411 thousand 075 calls. Of the 411 thousand emergency calls, 392 thousand or 96% were completed, emergency calls - 19 thousand, or 4%.
Compliance with financial indicators for 2015 based on the results of the first half of the year amounted to 48%. With a plan of 1 billion 339 million rubles, the actual result was 642 million rubles.
In the structure of EMS calls, diseases of the cardiovascular system make up the highest percentage of the total number of calls.
In order to monitor compliance with the terms, procedures and standards of medical care for patients with acute cerebrovascular accidents and acute coronary syndrome in primary vascular departments, the use of compulsory health insurance by medical organizations, unscheduled thematic inspections of all primary vascular departments of the Stavropol Territory were carried out.
As a result of the inspections, the following problems and violations were identified. The bed capacity of the PSO in most organizations does not correspond to the volume of assistance actually provided in connection with attachment to the PSO in accordance with the order of the Ministry of Health of the UK dated July 08, 2013 No. 01-05/764 of municipalities and urban districts, and medical care in the PSO is provided on attached, not estimated beds. Which leads to exceeding the approved volumes.
The implementation of the planned volumes of medical care based on the results of the first half of 2015 in the PSO was as follows:
“Regional Center SVMP No. 1” – 57%;
"GKB" of Pyatigorsk - 55%;
"City Clinical Hospital No. 3" of Stavropol - 43%;
“Essentuki Central City Hospital” – 43%;
"Kislovodsk Central City Hospital" - 95%;
“City Hospital” of Nevinnomyssk – 68%;
“Petrovskaya Central District Hospital” – 30%.
There is an extremely low implementation of planned indicators of thrombolytic therapy in all medical organizations that have a PSO in their structure. At the same time, the purchase of necessary drugs is carried out in full for 2015, as a result of which there is a high probability of expiration of expensive thrombolytics.
As a result of the structural analysis of interrupted cases of treatment in the PSO, it was shown that the economic losses of the PSO for the first half of 2015 amounted to a total of 39 million rubles. The main reasons for the formation of interrupted treatment cases are:
deaths – 625 cases; transfer to other medical organizations – 280 cases; discharge for reasons beyond the control of the medical organization – 187 cases.
The highest volume of economic losses due to interrupted cases of treatment in the PSO for the first half of 2015 was noted in:
“Essentuki Central City Hospital” – 6 million rubles;
“Kislovodsk Central City Hospital” – 4 million rubles;
"GKB" of Pyatigorsk - 7 million rubles;
"City Clinical Hospital No. 3" of Stavropol - 11 million rubles.
As a result of checking the reasons for interrupted cases, it was revealed that in the invoice registers interrupted cases of treatment in the PSO with the outcome of recovery were billed for payment, but with deviations in the duration of the patient’s treatment from the approved average duration by 2-3 days, which could have been billed as completed cases treatment. These facts have been noted in all medical organizations that have PSOs in their structure.
The billing registries do not include codes for services provided to patients, including the code for thrombolytic therapy, which significantly affects the cost of a treatment case in one direction or another.
This problem has been identified in all medical organizations of the Stavropol Territory. Based on this, there is a violation in terms of the correctness and validity of the application of tariffs and the formation of the cost of cases of medical care.
A comparative analysis of primary medical documentation and information in billing registers showed the following violations.
Cases of treatment included in the DRG “Cerebral infarction, with thrombolysis” and “Unstable angina, myocardial infarction, pulmonary embolism with thrombolysis” are billed and paid for as completed cases with 100% payment, and the medical history records a transfer to the RSC after thrombolytic therapy on the first day from the onset of the disease. In fact, these are interrupted cases of treatment according to the terms of the tariff agreement. These violations were noted in the Essentuki Central City Hospital and the City Clinical Hospital of Pyatigorsk.
Defects in the preparation of primary medical documentation were identified, which complicate the examination of the quality of medical care in terms of determining contraindications to thrombolytic therapy, and incorrect completion of checklists for deciding the possibility of thrombolysis.
Facts were revealed that cases of treatment included in the DRG “Cerebral infarction, with thrombolysis” were offered for payment, where in fact thrombolytic therapy was not carried out, thrombolytic drugs were not used in the treatment of patients, the patients were treated not in the PSO, but in the neurological department of the hospital.
For all reviewed medical histories, calculations were requested for the actual costs incurred for each PSO patient. The analysis showed that in most cases, the costs of diagnosis and treatment exceed the funds received, and the actual average duration of treatment has significant deviations from the approved one and ranges from 3 to 25 days.
In this regard, the commission for the development of the territorial compulsory health insurance program approved for all levels of medical organizations, regardless of the duration of the patient’s actual stay, an interrupted case of medical care attributed to the DRG specified in table 11.1 of the tariff agreement must be presented for payment with a coefficient of 0.8 .
Based on the results of the inspections, TFOMS SK proposes, in order to reduce the mortality rate in medical organizations and reduce the mortality rate of the population of the Stavropol Territory from diseases of the circulatory system, which are the main causes of premature mortality and disability of the population, to bring the quality of medical care provided to PSO patients in accordance with the approved procedures and standards of medical care.
TFOMS UK conducted an analysis of the cash and actual execution of financial support for medical organizations under the territorial compulsory medical insurance program, which revealed ineffective planning of financial and economic activities.
In addition, I would like to note that improper planning and organization of the treatment process, as well as non-compliance with the volume of the state assignment for the provision of medical care by type of expense, based on the approved plan of financial and economic activities, leads to the formation of accounts payable.
In general, in the region, accounts payable as of January 1, 2015 amounted to 204 million rubles and over the 6 months of this year increased by 463 million rubles compared to the beginning of the year. or 3.3 times, which as of July 1, 2015 amounted to 667 million rubles or 227%.
Thus, in the Regional Perinatal Center, accounts payable as of July 1, 2015 amounted to 13.9 million rubles, or 155% from the beginning of the year.
In the Novoselitskaya Central District Hospital, accounts payable as of July 1, 2015 amounted to 6.5 million rubles, or 46.3% from the beginning of the year.
In the Neftekumsk Central District Hospital, accounts payable as of July 1, 2015 amounted to 25.7 million rubles, or 134.2% from the beginning of the year.
In Andropovskaya Central District Hospital, accounts payable as of July 1, 2015 amounted to 12.9 million rubles, or 174.5% from the beginning of the year.
According to monitoring data for the 1st half of 2015, the target indicators for the ratio of the average wages of doctors, paramedical and junior medical personnel in the Stavropol Territory as a whole have been met.
The preparation of wage reports by order of the Federal Compulsory Medical Insurance Fund No. 65 dated March 26, 2013 continues this year. Wage issues are under special control in the Compulsory Medical Insurance Fund. As part of the implementation of this order, inspections of medical organizations continue to be carried out on the facts of a decrease in the average salary of medical personnel compared to the level of last year and compliance with target indicators for the ratio of average salaries by category of personnel.
A comparative analysis of the average salary approved according to the Road Map for 2015 and monitoring data by personnel categories in the compulsory medical insurance system for the 1st half of 2015 was also carried out.
The analysis showed that in some medical organizations, while indicators for some categories of employees are exceeded, for other specialists there is a failure to meet the average salary approved by the Road Map for 2015.
At the same time, in some medical organizations there is an overfulfillment of the planned salary indicators approved by the Road Map for 2015.
For example, an analysis carried out at the Novoselitsk Central District Hospital of the volume of medical care under the territorial compulsory health insurance program revealed irrational planning of financial and economic activities. Salaries at the end of the first half of 2015 exceeded the planned indicators according to the “road map” for doctors by 26.8%, for paramedical personnel by 8.2% and junior ones by 5.0%. Thus, in the Novoselitsk Central District Hospital, the actual payroll with accruals for the first half of 2015 exceeded the indicators approved by the road map of the Moscow Region by 4 million 240 thousand rubles, or 10%.
During the inspection of the Neftekumsk Central District Hospital, when analyzing the cash and actual execution of financial support for the volume of medical care under the territorial compulsory medical insurance program for the 1st half of 2015, irrational planning of financial and economic activities was revealed, in particular the diversion of funds from the expense item “salaries with accruals for wages” for the item “medicines and dressings” in the absence of financial savings provided for labor costs. At the same time, wages at the end of the first half of 2015 exceeded the planned indicators according to the state assignment by 10%, and according to the “road map” by 5%. In the absence of financial support, the volume of purchases of medicines increased unreasonably, as a result, as of July 1, 2015, accounts payable amounted to 17.6 million rubles.
Thus, the existing accounts payable and the remaining balance of medicines in the warehouse and in the departments will not allow ensuring a high-quality treatment process in accordance with the standards of medical care until the end of 2015. Taking into account the ongoing monitoring of wages and the shortcomings identified during inspections, it is advisable to strictly follow the indicators provided for by the road map.
Please note that the assessment of the activities of medical organizations depends on the quality of the reports provided regarding wages, analytical tables, and analysis of indicators. Based on the reporting of the Federal Compulsory Medical Insurance Fund of the UK, analytical reports are provided to the regional government, the Ministry of Health of the UK, and the Compulsory Medical Insurance Fund. Analysis of indicators of reporting forms is used by regulatory authorities during inspections.
TFOMS SK and SMO conducted sociological monitoring of citizens' satisfaction with the medical services provided. The study of citizens' satisfaction with the quality of medical care in the compulsory medical insurance system is a socially significant indicator that characterizes the activities of the compulsory medical insurance system as a whole.
In the first half of 2015, 33 thousand people took part in the survey. Sociological monitoring showed that the number of those satisfied with the medical care provided decreased by 2%, the number of dissatisfied people increased by 1%, the proportion of respondents who were partially satisfied with the medical care provided increased, and the number of respondents who were undecided. attitude towards medical care.
The population of the Stavropol Territory is most satisfied with inpatient medical care; respondents are least satisfied with the organization of outpatient medical care, including the low availability of specialist consultations, laboratory and instrumental studies. The level of satisfaction with the organization of work in children's hospitals is higher.
Dear Colleagues!
Based on the results of the analysis, we see that there is a clear tendency to exceed the planned volumes for 24-hour inpatient and outpatient care. I would like to remind you that an Agreement has been concluded between the Ministry of Health of the Russian Federation, the Federal Compulsory Medical Insurance Fund and the Government of the UK, which clearly establishes standards for the volume of medical care provided to residents of the UK. Financial support for the list of insured events, types and conditions of medical care is provided subject to the fulfillment of the requirements established by the basic and territorial Compulsory Medical Insurance Program. Responsibility for fulfilling all the terms of the Agreement, as you understand, lies not only with the Government of the UK, the Ministry of Health, and the Fund, but also with the direct executors implementing the territorial Program, that is, with you, dear leaders. Exceeding the volume of the state assignment will be clearly monitored by both the Fund and medical insurance organizations. Appropriate measures will be taken for any violations identified.
In conclusion, I would like to say that work is already underway to plan the state task for 2016. Taking into account the analysis of the activities of medical organizations for the first half of 2015, I ask you to take into account all the problems noted in the report and would like to direct the heads of medical institutions to more rational and effective planning of the medical care provided, financial and economic activities, in order to avoid economic losses in 2016 and, as a consequence, insufficient financial support for medical organizations.
Ministries
health care of the Kaliningrad region
and TFOMS of the Kaliningrad region
dated March 15, 2019 N 167/102
Regulations
monitoring and control over the implementation of the volumes of medical care and financial resources established by the decision of the Commission for the development of the territorial program of compulsory health insurance of the Kaliningrad region
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abbreviations used in the Regulations
|
Reduction |
Definition |
|
VMP |
High-tech medical care |
|
Commission |
Commission for the development of the Territorial Compulsory Medical Insurance Program |
|
MO |
Medical organization participating in the implementation of the Compulsory Medical Insurance TP |
|
IEC |
Medical and economic control |
|
MEE |
Medical and economic examination |
|
Compulsory medical insurance |
Compulsory health insurance |
|
Reporting period (month) |
The period (month) during which medical care was provided to insured persons, incl. previously started cases of treatment have been completed |
|
Working group |
Working group under the Commission for the development of the Compulsory Medical Insurance TP |
|
Register of medical care |
Electronic register of personalized records of information on medical care provided to insured persons |
|
SMO |
Medical insurance organization |
|
TP compulsory medical insurance |
Territorial compulsory medical insurance program of the Kaliningrad region |
|
TFOMS |
Territorial Compulsory Medical Insurance Fund of the Kaliningrad Region |
|
ECMP |
Examination of the quality of medical care |
|
GBUZ KO |
State budgetary healthcare institutions of the Kaliningrad region |
I. Fundamentals
1. These Regulations were developed in accordance with the Federal Law of November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation”, Order of the Ministry of Health and Social Development of Russia dated 02/28/2011 N 158n “On Approval of the Rules of Compulsory Medical Insurance”, Order of the Ministry of Health of the Russian Federation dated December 24, 2012 N 1355n "On approval of the form of a standard agreement for the provision and payment of medical care under compulsory medical insurance", by order of the Ministry of Health and Social Development of Russia dated 09.09.2011 N 1030n "On approval of the form of a standard agreement on the financial provision of compulsory medical insurance", by order Federal Compulsory Medical Insurance Fund dated December 1, 2010 N 230 “On approval of the Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance.”
2. The Regulations establish uniform organizational and methodological principles for monitoring and controlling the volume of medical care and financial resources within the framework of the compulsory health insurance program.
3. Basic principles of monitoring and control:
1) monitoring and control of the implementation of the volumes established by the decision of the Commission is carried out on an accrual basis from the beginning of the year, taking into account the implementation of quarterly and annual plans in the context of the conditions of medical care and in the context of the Moscow Region;
2) the monthly plan is conditionally considered to be 1/3 of the volume established by the decision of the Commission for the Moscow Region for the quarter. The fulfillment of the plan is calculated on an accrual basis for the reporting period from the planned volumes conditionally calculated for a given period, based on the volumes of medical care actually accepted by the health care organization for payment, taking into account the results of the IEC (with the exception of the results of the IEC according to the code of grounds for refusal to pay for medical care 5.3.2 " Presentation for payment of cases of medical care in excess of the distributed volume of medical care established by the decision of the Commission for the development of the territorial program");
3) the planned volumes in respect of which monitoring and control are carried out are the volumes approved by the latest decision of the Commission;
4) monitoring and control are carried out in relation to the volumes of medical care and financial resources established by the decision of the Commission, including the volumes of separately planned types of medical care (medical services):
In general, for TP compulsory medical insurance, for all municipalities for each condition of medical care: outpatient care (the number of visits in total, including for preventive and other purposes (including individual events), the number of emergency visits, the number of visits and appeals regarding the disease ; emergency medical care (calls); inpatient care, including emergency medical care (hospitalizations, bed days); in a day hospital (treatment cases, patient days);
By profiles, groups and types of HFMP in accordance with the distribution of HFMP volumes between municipalities approved by the Commission;
For certain types of primary health care and primary specialized medical care in an outpatient setting, not included in the per capita standard for financing outpatient care for attached persons (emergency medical care, preventive measures, dental medical care, methods of renal replacement therapy, and other types approved by the decision of the Commission);
For certain types and profiles of specialized medical care in the context of clinical and statistical groups of diseases and separately paid services (medical rehabilitation, methods of renal replacement therapy, in vitro fertilization, chemotherapy of malignant neoplasms, the use of genetically engineered drugs, operations on the visual organs (level 5, 6 in the context of a certain list of services), complex treatment with the use of immunoglobulin preparations) and other clinical and statistical groups of diseases approved by the decision of the Commission);
5) the volumes of medical care provided (including certain types of medical care and medical services) established for the year with a quarterly breakdown and reasonable subsequent adjustments are subject to payment;
6) as part of the control of volumes established by the Commission, the acceptance of registers for medical care provided, including VMP, other separately planned types of medical care (medical services), is carried out within the quarterly plan;
7) acceptance of registers of medical care in excess of the quarterly plan established by the Commission is carried out on the basis of requests from medical organizations recognized by the Commission as justified, with subsequent adjustment of quarterly and annual volumes of medical care taking into account actual execution;
8) adjustment of the volume of medical care is carried out:
In general, for TP compulsory medical insurance within the limits established for the corresponding year according to the terms of provision;
By redistributing volumes between medical organizations, taking into account the reorganization of medical organizations, the closure and opening of departments, the consumption of medical care by insured persons, including those determined by the routing of patient flows in a three-level system of medical care;
For Moscow Region by changing the annual plan or without changing the annual plan with quarterly redistribution in accordance with the application, to change the established volumes;
If a justified application of the Ministry of Defense for quarterly redistribution when accepting medical care registers is recognized in excess of the quarterly plan established by the Commission, the adjustment is carried out by increasing the quarterly plans specified in the application and reducing the plan for subsequent quarters without increasing the annual plan;
For high medical care by redistributing the volume of medical care within the framework of compulsory medical insurance;
For preventive measures by redistributing the volume of medical care between municipalities within the framework of the annual volumes established for a specific event;
In terms of volumes of individual expensive medical technologies through redistribution between medical organizations within the established annual volumes for a specific medical technology;
9) the reasons for a justified excess of the planned volumes/justified application for changing the established volumes of medical care may be:
An increase in the number and/or a change in the gender and age composition of insured persons who have chosen a given medical organization for the provision of primary health care or are sent to this medical organization in accordance with routing, confirmed by acts of reconciliation with the health insurance service, which has led to an increase in the consumption of medical care by insured persons;
Changes in the routing of patient flows, including due to the reorganization of the medical organization, changes in the structure of the medical organization (opening of new departments, medical appointments, increase in bed capacity), confirmed by the relevant regulations, which led to an increase in the consumption of medical care by insured persons;
Outbreaks of infectious diseases (exceeding the incidence rate compared to long-term averages), confirmed by Rospotrebnadzor data, emergencies, man-made disasters, natural disasters, etc., other reasons leading to a significant increase in the volume of emergency and/or emergency medical care;
10) in other cases when the obligation of the Ministry of Defense to manage the process of hospitalization in round-the-clock and day hospitals in the form of regulation in the context of forms of medical care (emergency, planned), which is expressed in exceeding the volume of planned medical care, is violated, submitting applications to the Ministry of Defense to change the established volumes medical care is unfounded.
When providing outpatient medical care in the context of requests, visits, emergency medical care and other conditions for the provision of medical care, which is expressed in exceeding the volume of listed medical activities (for example, visits), submitting applications to the Ministry of Defense for changing the established volumes of medical care is unfounded.
11) within the framework of monitoring the volume of medical care and financial resources, the measures provided for by the FFOMS order of December 1, 2010 N 230 “On approval of the Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance” are carried out.
II. Medical organizations
4. Organize the provision of medical care in accordance with the Territorial Program of State Guarantees of free provision of medical care to citizens in the Kaliningrad Region within the scope established by the decision of the Commission, in accordance with the agreement for the provision and payment of medical care under compulsory health insurance.
5. Monitor the completed volumes of medical care according to the conditions of provision on a monthly accrual basis from the beginning of the year.
6. Take measures to prevent excess of the volume of medical care (according to the conditions of provision and certain types of medical care or medical services) established by the decision of the Commission for the corresponding period, by regulating the priority for planned hospitalization, maintaining logs of planned hospitalization, strengthening the role of the outpatient clinic, development of day hospitals, etc.
7. Conduct an analysis of the performance indicators of the Ministry of Health (the function of the medical position, the structure of visits, the structure of hospitalizations, the average occupancy of a bed, the duration of hospitalization, the proportion of hospitalized patients on a planned and urgent basis, the waiting time for a planned hospitalization, the cost of a unit of medical care, etc. ) for timely adoption of management decisions, including the redistribution of volumes of medical care between structural divisions, subject to agreement with the Ministry of Health of the Kaliningrad Region.
8. Within 5 working days after making changes to the structure of the bed capacity and day hospital places, this information is brought to the attention of the TFOMS and SMO with the provision of the structure of the institution approved by the Ministry of Health of the Kaliningrad Region.
9. If there is a justified need to change the volume of medical care established by the decision of the Commission, a single application is formed in accordance with Appendix No. 1 to these Regulations and sent to:
1) the chairman of the commission for the development of the territorial compulsory health insurance program (Ministry of Health of the Kaliningrad Region);
2) the deputy chairman of the commission for the development of the territorial compulsory health insurance program (territorial compulsory health insurance fund).
10. The application of the Ministry of Defense for changing the established volumes of medical care can be of two types: for quarterly redistribution of volumes without changing the annual plan and for changing the annual plan:
1) if there is a justified need to load medical care registers in excess of the previously established quarterly plan, the Ministry of Defense forms an application for quarterly redistribution - within the established annual plan;
2) to increase the volume of medical care in excess of the established annual plan - in the case where overfulfillment of the quarterly plan will reasonably lead to overfulfillment of the annual volume of medical care;
3) an application to change volumes must be sent no later than 5 working days of the month following the reporting period. Copies of the necessary documents are attached to the application (orders on the reorganization of the Moscow Region, redistribution of patient flows, on the opening/closing of departments, etc.). Applications submitted in violation of this procedure will not be considered;
4) if the planned volumes of medical care are not fulfilled, an application for quarterly redistribution of these volumes is not submitted; redistribution of the volumes of medical care not fulfilled by the Ministry of Defense, if necessary, is carried out by the Commission on the proposals of the Working Group.
11. MO, which, by decision of the Commission, established the volumes of HFMP for the corresponding year:
1) take measures to prevent excess volumes of primary care by type of primary care established by the decision of the Commission, by regulating the priority for planned hospitalization, maintaining priority logs for the provision of primary care;
2) enter information about the fact of providing VMP into the specialized information system of the Ministry of Health of the Russian Federation;
3) send an application to the Chairman of the Commission to change the planned volumes of HFMP with justification for making the changes.
12. Conclude an additional agreement on amending the contract for the provision and payment of medical care under compulsory health insurance with the health insurance company in accordance with the decision of the Commission.
III. Insurance medical organizations
13. On a monthly basis, on an accrual basis, from the beginning of the year, monitoring of the volumes of medical care performed by the Ministry of Defense and financial resources under the conditions of providing medical care is carried out.
14. Analyze the performance indicators of the established volumes and the reasons for exceeding/non-fulfilling the volumes of medical care and financial resources for all conditions of medical care.
15. Establish the validity of the reasons for exceeding/non-fulfilling the volume of medical care by analyzing the structure of patients treated, the presence of referrals for planned hospitalization, the share of emergency/urgent hospitalizations, including for certain classes of diseases, the planned and actual duration of treatment, the indicator of operational activity, etc. Evaluate measures taken by the head of the Ministry of Defense to regulate the priority for planned hospitalization, including for emergency medical care, continuity in the work of hospitals, clinics, and day hospitals.
16. Conduct MEE, ECMP, including face-to-face inspections, in order to identify cases of unjustified hospitalizations (including repeated), non-core hospitalizations, as well as other violations of the procedures and standards of medical care, violations of the preparation of primary medical documentation and the formation of registers of accounts leading to unreasonable excess of the established volumes of medical care.
17. By decision of the Commission, if the fact of exceeding in the reporting period the volumes of medical care established for the municipality as a whole is recognized as unfounded, in accordance with the order of the Compulsory Medical Insurance Fund dated December 1, 2010 N 230 “On approval of the Procedure for organizing and monitoring volumes, timing, quality and conditions provision of medical care under compulsory medical insurance" is carried out by the IEC, including repeated ones, in cases of medical care presented for payment by the Ministry of Defense in excess of the established amount:
1) the number of cases included by the CMO in the IEC act should not exceed the number of cases presented to the MO for payment of this CMO in excess of the established planned volume;
2) if the excess of the established plan for a specific medical organization is greater than the excess for the medical organization as a whole, then the number of cases included in the IEC act should not exceed the total number of cases of medical care presented to the medical organization for payment in excess of the plan.
18. According to the Commission’s decision to amend the distribution of volumes of medical care and/or volumes of financial resources between municipalities within the framework of the TP, compulsory medical insurance enters into additional agreements to contracts for the provision and payment of medical care under compulsory health insurance with municipalities.
IV. Ministry of Health of the Kaliningrad Region
19. Carries out work to optimize and repurpose hospital beds in subordinate municipalities in accordance with standards and routing of patient flows, taking into account the level of medical care.
20. Informs the Working Group in advance about the planned reorganization of the Ministry of Defense, closure/opening of departments and changes in patient routing.
21. Prepares materials for consideration at meetings of the Working Group and the Commission within its competence.
22. Conducts monthly monitoring of the implementation of planned volumes of HFMP by type of HFMP and MO, as well as analysis of applications from MOs for the redistribution of established volumes of HFMP; proposals on the redistribution of planned volumes of high-volume MP by types of high-volume MP with justification are sent to the Working Group.
23. With the involvement of the main freelance specialists of the Ministry of Health of the Kaliningrad Region of the relevant profiles:
1) conducts an analysis of the execution of volumes for individual expensive medical technologies established by the decision of the Commission on a quarterly basis;
2) provides information on the validity of exceeding the volumes of certain expensive medical technologies in the context of MO and sends to the Working Group proposals for additional loading of these volumes in excess of the quarterly plan and redistribution of volumes between quarters and (or) MO.
V. Territorial Compulsory Medical Insurance Fund of the Kaliningrad Region
24. On a monthly basis, on an accrual basis, monitors and analyzes the implementation of the volumes of medical care and financial resources established by the decision of the Commission, in the context of the Ministry of Defense and separately planned types of medical care (medical services).
25. Prepares materials for consideration at meetings of the Working Group and the Commission.
26. By decision of the Commission, it redistributes the volume of medical care and financial resources between the Moscow Region and the Health Insurance Company.
27. Monitors the activities of the health insurance service, including by organizing repeated monitoring of the volumes, timing, quality and conditions of providing medical care under compulsory medical insurance, in order to identify violations in the provision of medical care leading to exceeding the established volumes.
28. Conducts an analysis of violations identified during monitoring of the volumes, timing, quality and conditions of providing medical care under compulsory medical insurance, as well as the structure of medical care in the Moscow Region, which exceeded the volumes of medical care and financial resources established by the Commission.
29. Informs the Ministry of Health of the Kaliningrad Region, as well as the Working Group, about violations identified during monitoring (including repeated) of the volumes, timing, quality and conditions of providing medical care under compulsory medical insurance.
30. Conducts an assessment of the volumes of financing established by the decision of the Commission and the amounts actually presented for payment for compliance with the standards of financial costs per unit of medical care established by the Compulsory Medical Insurance TP.
31. Conducts an analysis of the planned and actual cost of a unit of medical care in accordance with the Tariff Agreement on Compulsory Medical Insurance to identify the reasons for the deviation of actual cost indicators from planned indicators.
32. Within 5 working days after the meeting of the Commission, it brings to the attention of interested parties information about the decisions made by the Commission by posting it on the official website of the TFOMS.
VI. Working group under the Commission for the development of the territorial compulsory medical insurance program
33. Analyzes the implementation of the Compulsory Medical Insurance TP according to the conditions for the provision of medical care in the context of municipalities, types of medical care, separately planned types of medical care (medical services).
34. Considers applications received from medical organizations included in the register in the current financial year.
35. Taking into account the proposals of the Ministry of Health of the Kaliningrad Region, the TFOMS of the Kaliningrad Region is preparing a draft decision for consideration by the Commission:
1) on the validity of requests from the Ministry of Defense for the formation of additional registers of medical care in excess of the quarterly plan and the need to adjust the established volumes of medical care;
2) on the validity of applications from the Ministry of Defense for changes in the established volumes of medical care.
36. If necessary, hears at meetings of the Working Group representatives of the Ministry of Defense who have exceeded the volume of medical care established by the decision of the Commission.
37. Submits for consideration by the Commission proposals for establishing/redistributing volumes of medical care and financial resources between municipalities as a whole, as well as proposals for establishing/redistributing volumes by type of medical care, separately planned types of medical care (medical services).
- Appendix No. 1. Application of a medical organization to change the volume of medical care established by the decision of the commission for the development of a territorial compulsory health insurance program
Regulatory acts Federal Law 326-FZ of the city “On compulsory health insurance in the Russian Federation” (Articles 20, 36) Federal Law 323-FZ of the city “On the fundamentals of protecting the health of citizens in the Russian Federation” (Articles 10, 80, 81 ) Decree of the Government of the Irkutsk Region 685-pp from the city “On TPGG free provision of medical care to citizens in the Irkutsk region for 2015 and for the planning period of 2016 and 2017” Decree of the Government of the Irkutsk Region 689-pp dated “On TPGG free provision to citizens medical care in the Irkutsk region for 2016"
Risk factors influencing the implementation of volumetric indicators of TPGG Uneven distribution of load on outpatient and inpatient services during the day, week, month, year Lack of staffing. Continuous changes in the number of attached population, gender and age structure Resistance of staff to fulfill the planned volumes approved by the TPGG Fluctuations in the level of morbidity of the population Discrepancy between the estimated capacity of the institution and the volume of medical care provided Transport accessibility of medical care
Execution of planned volumes of TPGG in 2015 in the provision of outpatient care 2015 Plan Actual % of execution Total visits, 5% Visits for preventive and other purposes, 6% Visits provided in an emergency form, 1% Visits included in requests in connection with disease, 4% Calls regarding diseases, 4%
Fulfillment of planned volumes of TPGG in 2015 for the provision of inpatient care 2015 Plan Fact % of execution In a 24-hour hospital setting Bed days in 24-hour hospital beds, 1% Case of hospitalization, 4% In a day hospital setting Patient days in day hospitals, 9%
Measures to manage risk factors in order to achieve volumetric indicators of TPGG Planning for the implementation of approved indicators of TPGG Weekly, monthly, quarterly monitoring of the implementation of planned indicators Timely correction of planned indicators Work to attract personnel Monthly material incentives for employees based on the results of achieving approved planned indicators Selection of the optimal operating mode for outpatient clinics services and patient flow management
Algorithm for calculating planned indicators 1. Analysis of the implementation of planned indicators for the previous period 2. Based on the results of the analysis, planned volumes are approved for departments and staff positions: 2.1. for each full-time position of outpatient reception, a visit plan is calculated based on the function of the medical position for a month, a year 2.2. the estimated visit plan is brought into line with the planned indicators of TPGG 2.3. for inpatient departments - the distribution of planned volumes between inpatient departments is carried out taking into account the nature of hospitalization, actual volumes for the previous year, and the average duration of patient treatment;
Vision for the implementation of the volume of medical care approved by the TPGG for 2016 Cases of hospitalization in a 24-hour hospital Number of patients treated in a day hospital Treatments regarding illness Visits for preventive and other purposes Emergency visits 2015 fact plan plan
In accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Health Insurance in the Russian Federation" I order:
1. Approve the attached Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance (hereinafter referred to as the Procedure).
2. The heads of territorial compulsory health insurance funds and medical insurance organizations should use the attached Procedure when organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance.
Chairman A. Yurin
The procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance
I. General provisions
1. This Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance (hereinafter referred to as the Procedure) was developed in accordance with the Federal Law of November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation "(Collection of Legislation of the Russian Federation, 06.12.2010, N 49, Art. 6422) and determines the rules and procedure for organizing and conducting control over the volumes, timing, quality and conditions of medical care by medical organizations in the volume and on the terms established by the territorial compulsory health insurance program and the contract for the provision and payment of medical care under compulsory health insurance.
2. The purpose of this Procedure is to regulate measures aimed at realizing the rights of insured persons to receive free medical care in the volumes, terms and conditions of appropriate quality in medical organizations established by the territorial compulsory health insurance program and the agreement for the provision and payment of medical care under compulsory health insurance. participating in the implementation of compulsory health insurance programs.
II. Goals of controlling volumes, timing, quality and conditions of provision
medical assistance under compulsory health insurance
3. Control of the volume, timing, quality and conditions of the provision of medical care under compulsory health insurance (hereinafter referred to as control) includes measures to verify the compliance of the medical care provided to the insured person with the terms of the contract for the provision and payment of medical care under compulsory health insurance, implemented through medical economic control, medical and economic examination and examination of the quality of medical care.
4. The object of control is the organization and provision of medical care under compulsory health insurance. Subjects of control are territorial compulsory health insurance funds, medical insurance organizations, medical organizations that have the right to carry out medical activities and are included in the register of medical organizations operating in the field of compulsory health insurance.
5. Control objectives:
5.1. ensuring free provision of medical care to the insured person in the amount and under the conditions established by the territorial compulsory health insurance program;
5.2. protection of the rights of the insured person to receive free medical care in the amount and under the conditions established by the territorial compulsory health insurance program, of appropriate quality in medical organizations participating in the implementation of compulsory health insurance programs, in accordance with contracts for the provision and payment of medical care under compulsory health insurance ;
5.3. prevention of defects in medical care resulting from inconsistency of the provided medical care with the health status of the insured person; non-compliance and / or incorrect implementation of procedures for the provision of medical care and / or standards of medical care, medical technologies by analyzing the most common violations based on the results of control and taking measures by authorized bodies;
5.4. checking the fulfillment by insurance medical organizations and medical organizations of obligations to pay and provide free medical care to insured persons under compulsory health insurance programs;
5.5. checking the fulfillment of obligations by insurance medical organizations to study the satisfaction of insured persons with the volume, accessibility and quality of medical care;
5.6. optimizing the cost of paying for medical care in the event of an insured event and reducing insurance risks in compulsory medical insurance.
6. Control is carried out through medical and economic control, medical and economic examination, and examination of the quality of medical care.
III. Medical and economic control
7. Medical and economic control in accordance with Part 3 of Article 40 of the Federal Law of November 29, 2010 N 326-FZ “On Compulsory Medical Insurance in the Russian Federation” (hereinafter referred to as the Federal Law) - establishing the conformity of information on the volume of medical care provided to insured persons on the basis of the registers of accounts provided for payment by the medical organization, the terms of contracts for the provision and payment of medical care under compulsory health insurance, the territorial compulsory health insurance program, methods of payment for medical care and tariffs for payment of medical care.
8. Medical and economic control is carried out by specialists from medical insurance organizations and territorial compulsory health insurance funds.
9. During medical and economic control, all cases of medical care provided under compulsory health insurance are monitored in order to:
1) checking account registers for compliance with the established procedure for information exchange in the field of compulsory health insurance;
2) identification of a person insured by a specific medical insurance organization (payer);
3) checking the compliance of the medical care provided:
a) territorial compulsory health insurance program;
b) the terms of the contract for the provision and payment of medical care under compulsory health insurance;
c) a current license of a medical organization to carry out medical activities;
4) checking the validity of the application of tariffs for medical services, calculating their cost in accordance with the methodology for calculating tariffs for payment of medical care, approved by the authorized federal executive body, methods of payment for medical care and tariffs for payment of medical care and the agreement for the provision and payment of medical care for compulsory health insurance;
5) establishing that the medical organization does not exceed the volume of medical care established by the decision of the commission for the development of the territorial compulsory health insurance program, subject to payment from compulsory health insurance funds.
10. Violations identified in the registers of accounts are reflected in the act of medical and economic control (Appendix 1 to this Procedure) indicating the amount of reduction in the account for each register entry containing information about defects in medical care and / or violations in the provision of medical care.
In accordance with parts 9 and 10 of Article 40 of the Federal Law, the results of medical and economic control, drawn up by the relevant act in the form established by the Federal Compulsory Health Insurance Fund, are the basis for the application of measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care on compulsory health insurance and a list of grounds for refusing to pay for medical care (reducing payment for medical care) (Appendix 8 to this Procedure), and may also be the basis for conducting a medical and economic examination; organizing and conducting examination of the quality of medical care; carrying out repeated medical and economic control, repeated medical and economic examination and examination of the quality of medical care by the territorial compulsory medical insurance fund or medical insurance organization on the instructions of the territorial fund (except for control when making payments for medical care provided to insured persons outside the constituent entity of the Russian Federation, on territory of which the compulsory health insurance policy was issued).
IV. Medical and economic examination
11. Medical and economic examination in accordance with Part 4 of Article 40 of the Federal Law - establishing compliance of the actual terms of medical care, the volume of medical services presented for payment with the records in the primary medical documentation and the accounting and reporting documentation of the medical organization.
12. Medical and economic examination is carried out by a specialist expert (clause 78 of section XIII of this Procedure).
13. Medical and economic examination is carried out in the form of:
a) targeted medical and economic examination;
b) planned medical and economic examination.
14. Targeted medical and economic examination is carried out in the following cases:
a) repeated requests for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;
b) diseases with an extended or shortened treatment period by more than 50 percent of the established standard of medical care or the average for all insured persons in the reporting period with a disease for which there is no approved standard of medical care;
c) receiving complaints from the insured person or his representative regarding the availability of medical care in a medical organization.
15. Based on the medical and economic control carried out, a planned medical and economic examination is carried out on invoices submitted for payment within a month after the provision of medical care to the insured person under compulsory health insurance, in other cases it can be carried out within a year after the presentation of invoices for payment.
16. When conducting a planned medical and economic examination, the following are assessed:
a) the nature, frequency and causes of violations of the rights of insured persons to receive medical care under compulsory health insurance in the volume, terms, quality and conditions established by the contract for the provision and payment of medical care under compulsory health insurance;
b) the volume of medical care provided by the medical organization and its compliance with the volume established by the decision of the commission for the development of the territorial compulsory health insurance program to be paid from compulsory health insurance funds;
c) the frequency and nature of violations by a medical organization of the procedure for creating account registers.
17. The scope of inspections during a routine medical and economic examination of the number of bills accepted for payment for cases of medical care provided under compulsory health insurance is determined by the contract for the provision and payment of medical care under compulsory health insurance and is no less than:
8% - inpatient medical care;
8% - medical care provided in a day hospital;
0.8% - outpatient medical care.
If during a month the number of defects in medical care and/or violations in the provision of medical care exceeds 30 percent of the number of cases of medical care for which a medical and economic examination was carried out, in the next month the volume of inspections from the number of bills accepted for payment in cases provision of medical care should be increased by at least 2 times compared to the previous month.
18. In relation to a certain set of cases of medical care, selected according to thematic criteria (for example, the frequency and types of postoperative complications, duration of treatment, cost of medical services) in a medical organization in accordance with the plan agreed upon by the territorial compulsory health insurance fund, a planned thematic medical and economic examination.
19. Based on the results of the medical and economic examination, a specialist expert draws up a medical and economic examination report (Appendix 2 to this Procedure) in two copies: one is transferred to the medical organization, one copy remains in the medical insurance organization / territorial compulsory health insurance fund.
In accordance with Part 9 of Article 40 of the Federal Law, the results of a medical and economic examination, drawn up by the relevant act in the form established by the Federal Compulsory Health Insurance Fund, are the basis for applying to a medical organization the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care assistance for compulsory health insurance and a list of grounds for refusing to pay for medical care (reducing payment for medical care) (Appendix 8 to this Procedure), and may also be the basis for conducting an examination of the quality of medical care.
V. Quality examination
medical care
20. In accordance with Part 6 of Article 40 of the Federal Law, examination of the quality of medical care is the identification of violations in the provision of medical care, including assessment of the correct choice of medical technology, the degree of achievement of the planned result and the establishment of cause-and-effect relationships of identified defects in the provision of medical care.
21. An examination of the quality of medical care is carried out by checking the compliance of the medical care provided to the insured person with the contract for the provision and payment of medical care under compulsory health insurance, procedures for the provision of medical care and standards of medical care, and established clinical practice.
22. An examination of the quality of medical care is carried out by an expert on the quality of medical care included in the territorial register of experts on the quality of medical care (clause 81 of Section XIII of this Procedure) on behalf of the territorial compulsory health insurance fund or medical insurance organization.
23. Examination of the quality of medical care is carried out in the form of:
a) targeted examination of the quality of medical care;
b) planned examination of the quality of medical care.
24. A targeted examination of the quality of medical care is carried out within a month after the provision of an insured event (medical services) for payment, with the exception of cases determined by current legislation and the cases set out in subparagraph “e” of paragraph 25 of this section.
25. Targeted examination of the quality of medical care is carried out in the following cases:
a) receiving complaints from the insured person or his representative regarding the availability and quality of medical care in a medical organization;
b) the need to confirm the volume and quality of medical care for cases selected during medical and economic control and medical and economic examination;
c) deaths during the provision of medical care;
d) nosocomial infection and complications of the disease;
e) primary access to disability for persons of working age and children;
f) repeated justified appeal for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;
g) diseases with an extended or shortened treatment period by more than 50 percent of the established standard of medical care or the average for all insured persons in the reporting period with a disease for which there is no approved standard of medical care.
26. When conducting a targeted examination of the quality of medical care in cases selected based on the results of a targeted medical and economic examination, the general time frame for conducting a targeted examination of the quality of medical care may increase to six months from the date of submission of the invoice for payment.
When conducting a targeted examination of the quality of medical care in cases of repeated treatment (hospitalization) for the same disease, the established deadlines are calculated from the moment the invoice containing information about the repeated treatment (hospitalization) is submitted for payment.
The time frame for conducting a targeted examination of the quality of medical care from the moment the invoice is submitted for payment is not limited in cases of complaints from insured persons or their representatives, deaths, nosocomial infections and complications of diseases, primary disability of persons of working age and children.
27. Conducting a targeted examination of the quality of medical care in the event of complaints from insured persons or their representatives does not depend on the time that has passed since the provision of medical care and is carried out in accordance with Federal Law of May 2, 2006 N 59-FZ "On the procedure for considering citizens' appeals Russian Federation" and other regulatory legal acts regulating work with citizens' appeals.
28. The number of targeted examinations of the quality of medical care is determined by the number of cases requiring its implementation on the grounds specified in this Procedure.
29. A planned examination of the quality of medical care is carried out with the aim of assessing the compliance of the volumes, timing, quality and conditions of providing medical care to groups of insured persons, divided by age, disease or group of diseases, stage of medical care and other characteristics, conditions stipulated by the contract for provision and payment medical care under compulsory health insurance.
30. The scope of the planned examination of the quality of medical care is determined by the contract for the provision and payment of medical care under compulsory health insurance and is no less than:
in hospital - 5% of the number of completed cases of treatment;
in a day hospital - 3% of the number of completed cases of treatment;
when providing outpatient care - 0.5% of the number of completed cases of treatment based on the results of medical and economic control.
31. A planned examination of the quality of medical care is carried out in cases of medical care provided under compulsory health insurance, selected:
a) random sampling method;
b) for a thematically homogeneous set of cases.
32. A planned examination of the quality of medical care using a random sampling method is carried out to assess the nature, frequency and causes of violations of the rights of insured persons to timely receipt of medical care of the volume and quality established by the territorial compulsory health insurance program, including those caused by improper implementation of medical technologies that led to a deterioration in health status the insured person, additional risk of adverse consequences for his health, suboptimal use of the resources of the medical organization, dissatisfaction with the medical care of the insured persons.
33. A planned thematic examination of the quality of medical care is carried out in relation to a certain set of cases of medical care provided under compulsory health insurance, selected according to thematic criteria in each medical organization or group of medical organizations providing medical care under compulsory health insurance of the same type or in the same conditions.
The choice of topics is carried out on the basis of performance indicators of medical organizations, their structural divisions and specialized areas of activity:
a) hospital mortality, frequency of postoperative complications, initial disability of people of working age and children, frequency of re-hospitalizations, average duration of treatment, cost of medical services and other indicators;
b) the results of internal and departmental quality control of medical care.
34. The planned thematic examination of the quality of medical care is aimed at solving the following tasks:
a) identification, establishment of the nature and causes of typical (repetitive, systematic) errors in the diagnostic and treatment process;
b) comparison of the quality of medical care provided to groups of insured persons divided by age, gender and other characteristics.
35. A planned examination of the quality of medical care is carried out in each medical organization that provides medical care under compulsory health insurance at least once during the calendar year within the time limits determined by the inspection plan (clause 51 of Section VII of this Procedure).
36. An examination of the quality of medical care may be carried out during the period of provision of medical care to the insured person (hereinafter referred to as an in-person examination of the quality of medical care), including at the request of the insured person or his representative. The main goal of an in-person examination of the quality of medical care is to prevent and/or minimize the negative impact of defects in medical care on the patient’s health.
An expert in the quality of medical care, with notification to the administration of a medical organization, can conduct a tour of the divisions of a medical organization in order to monitor the conditions for the provision of medical care, prepare materials for an expert opinion, and also advise the insured person.
During the consultation, the insured person who applies is informed about his state of health, the degree of compliance of the medical care provided with the procedures for the provision of medical care and standards of medical care, the contract for the provision and payment of medical care under compulsory health insurance with an explanation of his rights in accordance with the legislation of the Russian Federation.
37. The expert in the quality of medical care who carried out the examination of the quality of medical care draws up an expert report containing a description of the conduct and results of the examination of the quality of medical care, on the basis of which an act of examination of the quality of medical care is drawn up.
In accordance with parts 9 and 10 of Article 40 of the Federal Law, the results of the examination of the quality of medical care, drawn up by the relevant act in the form established by the Federal Compulsory Health Insurance Fund (Appendices 5, 6 to this Procedure), are the basis for applying to a medical organization the measures provided for in the article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care under compulsory health insurance and a list of grounds for refusing to pay for medical care (reducing payment for medical care) (Appendix 8 to this Procedure).
Based on certificates of examination of the quality of medical care, authorized bodies take measures to improve the quality of medical care.
VI. The procedure for implementation by the territorial fund
compulsory health insurance activity control
medical insurance organizations
38. The Territorial Compulsory Medical Insurance Fund, on the basis of Part 11 of Article 40 of the Federal Law, exercises control over the activities of medical insurance organizations by organizing control over the volumes, timing, quality and conditions of medical care, conducts medical and economic control, medical and economic examination, examination of the quality of medical care. help, including again.
39. Repeated medical-economic examination or examination of the quality of medical care (hereinafter referred to as re-examination) - a medical-economic examination carried out by another specialist expert or another expert on the quality of medical care, an examination of the quality of medical care in order to verify the validity and reliability of conclusions on previously accepted conclusions made a specialist expert or an expert on the quality of medical care who initially conducted a medical and economic examination or examination of the quality of medical care.
A repeated examination of the quality of medical care can be carried out in parallel or sequentially with the first using the same method, but by a different expert on the quality of medical care.
40. The objectives of re-examination are:
a) checking the validity and reliability of the conclusion of a specialist expert or expert on the quality of medical care who initially conducted the medical and economic examination or examination of the quality of medical care;
b) monitoring the activities of individual expert specialists / experts on the quality of medical care.
41. Re-examination is carried out in the following cases:
a) the territorial compulsory medical insurance fund conducts a documentary inspection of the organization of compulsory medical insurance by a medical insurance organization;
b) identifying violations in the organization of control on the part of the medical insurance organization;
c) the unfoundedness and/or unreliability of the conclusion of the expert on the quality of medical care who conducted the examination of the quality of medical care;
d) receipt of a claim from a medical organization that has not been settled with the medical insurance organization (clause 73 of section XI of this Procedure).
42. The Territorial Compulsory Medical Insurance Fund notifies the medical insurance organization and the medical organization about the re-examination no later than 5 working days before the start of work.
To conduct a re-examination to the territorial compulsory health insurance fund, within 5 working days after receiving the relevant request, the medical insurance organization and the medical organization are required to provide:
medical insurance organization - copies of medical and economic control, medical and economic examination and examination of the quality of medical care necessary for re-examination;
medical organization - medical, accounting and reporting and other documentation, if necessary, the results of internal and departmental quality control of medical care, including those carried out by the health care management body.
43. The number of cases subjected to re-examination is at least 20% of the number of all examinations for the corresponding period of time.
44. The territorial compulsory health insurance fund sends the results of the re-examination, drawn up in an act (Appendix 7 to this Procedure), to the medical insurance organization and medical organization no later than 20 working days after the end of the inspection. The medical insurance organization and the medical organization are obliged to review the specified acts within 20 working days from the date of their receipt.
45. The medical insurance organization and the medical organization, in the event of no agreement with the results of the re-examination, send a signed act with a protocol of disagreements to the territorial compulsory health insurance fund no later than 10 working days from the date of receipt of the act.
The Territorial Compulsory Health Insurance Fund, within 30 working days from the date of receipt, reviews the act with a protocol of disagreements with the involvement of interested parties.
46. In accordance with Part 14 of Article 38 of the Federal Law, the territorial compulsory medical insurance fund, in the event of detection of violations of contractual obligations on the part of an insurance medical organization when reimbursing it for the costs of paying for medical care, reduces payments by the amount of identified violations or unfulfilled contractual obligations.
The list of sanctions for violations of contractual obligations is established by the agreement on financial support for compulsory health insurance, concluded between the territorial compulsory health insurance fund and the medical insurance organization.
In accordance with this agreement, if violations are detected in the activities of a medical insurance organization, the territorial compulsory medical insurance fund uses measures applied to the medical insurance organization in accordance with Part 13 of Article 38 of the Federal Law and the agreement on financial support of compulsory medical insurance or recognizes those applied by the medical insurance organization measures taken against a medical organization are unfounded.
47. The territorial compulsory medical insurance fund, when identifying violations in the organization and conduct of medical and economic examination and / or examination of the quality of medical care, sends a claim to the medical insurance organization, which contains information about the monitoring carried out over the activities of the medical insurance organization:
a) the name of the commission of the territorial compulsory health insurance fund;
b) date (period) of inspection of the medical insurance organization;
c) the composition of the commission of the territorial compulsory health insurance fund;
d) regulatory legal acts that are the basis for monitoring the activities of an insurance medical organization in organizing and conducting control and the reasons for conducting control;
e) facts of improper fulfillment by the medical insurance organization of contractual obligations to organize and conduct control, indicating re-examination reports;
f) the extent of responsibility of the medical insurance organization for identified violations;
g) attachments (copies of re-examination reports, etc.).
The claim is signed by the director of the territorial compulsory health insurance fund.
Fulfillment of the claim is carried out within 30 working days from the date of its receipt by the medical insurance organization, about which the territorial compulsory health insurance fund is informed.
48. If the territorial compulsory medical insurance fund identifies, during a re-examination, violations missed by the medical insurance organization during a medical-economic examination or examination of the quality of medical care, the medical insurance organization loses the right to use measures applied to the medical organization for a medical defect not detected in a timely manner. assistance and/or disruption in the provision of medical care.
49. The medical organization returns funds in the amount determined by the re-examination act to the budget of the territorial compulsory health insurance fund.
50. The Territorial Compulsory Health Insurance Fund analyzes requests from insured persons, their representatives and other subjects of compulsory health insurance based on the results of control carried out by the medical insurance organization.
VII. Interaction of subjects of control
51. The Territorial Compulsory Medical Insurance Fund coordinates the interaction of subjects of control on the territory of a constituent entity of the Russian Federation, carries out organizational and methodological work to ensure the functioning of control and protection of the rights of insured persons, coordinates the activity plans of medical insurance organizations in terms of organizing and conducting control, including plans inspections by medical insurance organizations of medical organizations providing medical care under contracts for the provision and payment of medical care under compulsory medical insurance.
52. When conducting a medical-economic examination and examination of the quality of medical care, the medical organization provides expert specialists and experts on the quality of medical care within 5 working days after receiving the relevant request with medical, accounting, reporting and other documentation, and, if necessary, the results of internal and departmental quality control medical care.
53. In accordance with Part 8 of Article 40 of the Federal Law, a medical organization does not have the right to interfere with the access of expert specialists and experts in the quality of medical care to the materials necessary for conducting a medical and economic examination, examination of the quality of medical care and is obliged to provide the requested information.
54. Employees involved in control are responsible for the disclosure of confidential information of limited access in accordance with the legislation of the Russian Federation.
55. Based on Article 42 of the Federal Law, the resolution of controversial and conflict issues arising during the control between a medical organization and a medical insurance organization is carried out by the territorial compulsory health insurance fund.
The commission informs interested parties and the executive authority of the constituent entity of the Russian Federation in the field of healthcare about the results of resolving controversial and conflict issues, about violations in the organization and conduct of control, in the provision of medical care in a medical organization.
VIII. Accounting and use
control results
56. Reports on the results of the control carried out are provided by medical insurance organizations to the territorial compulsory health insurance fund.
The medical insurance organization and the territorial compulsory medical insurance fund keep records of control acts.
Registration documents may be registers of acts of medical and economic control (Appendix 2 to this Procedure), medical and economic examination and examination of the quality of medical care.
The results of control in the form of reports are transferred to the medical organization within 5 working days.
It is possible to conduct electronic document flow between subjects of control using an electronic digital signature.
57. In the event that the act is delivered to the medical organization personally by a representative of the medical insurance organization / territorial compulsory health insurance fund, all copies of the act are marked with receipt indicating the date and signature of the recipient. When sending the act by mail, the specified document is sent by registered mail (with the preparation of an inventory) with notification.
The act can be sent to a medical organization in electronic form if there are guarantees of its reliability (authenticity), protection from unauthorized access and distortion.
58. The head of a medical organization or a person replacing him reviews the report within 15 working days from the date of its receipt.
If the medical organization agrees with the act and measures applied to the medical organization, all copies of the acts are signed by the head of the medical organization, certified with a seal, and one copy is sent to the medical insurance organization / territorial compulsory health insurance fund.
If the medical organization disagrees with the act, the signed act is returned to the medical insurance organization with a protocol of disagreements.
59. The territorial compulsory health insurance fund, based on an analysis of the activities of the subjects of control, develops proposals that help improve the quality of medical care and the efficiency of using compulsory health insurance resources and informs the executive body of the constituent entity of the Russian Federation in the field of healthcare and the territorial body of the Federal Service for Surveillance in Healthcare social development.
60. In accordance with Article 31 of the Federal Law, filing a claim or lawsuit against a person who caused harm to the health of the insured person in order to reimburse the costs of paying for medical care provided by an insurance medical organization is carried out on the basis of the results of an examination of the quality of medical care, documented in the relevant act.
IX. The procedure for informing insured persons about identified violations in the provision of medical care
under the territorial compulsory health insurance program
61. In order to ensure the rights to receive affordable and high-quality medical care, insured persons are informed by medical organizations, medical insurance organizations, territorial compulsory health insurance funds about identified violations in the provision of medical care under the territorial compulsory health insurance program, including the results of control.
62. Work with citizens’ appeals in the Federal Compulsory Medical Insurance Fund, territorial compulsory medical insurance funds and medical insurance organizations is carried out in accordance with the Federal Law of May 2, 2006 N 59-FZ “On the procedure for considering appeals from citizens of the Russian Federation” and other regulatory legal acts acts regulating work with citizens' appeals.
63. When a medical insurance organization or territorial compulsory medical insurance fund receives a complaint from the insured person or his representative regarding the provision of medical care of inadequate quality, the results of consideration of the complaint based on the results of the examination of the quality of medical care are sent to his address.
64. In medical insurance organizations that organize the service of representatives of medical insurance organizations to carry out work in medical organizations participating in the implementation of compulsory health insurance programs to protect the rights and legitimate interests of insured persons, representatives of medical insurance organizations take part in the preparation and placement of information materials on protection of the rights of insured persons and the results of control, and also provide insured persons receiving medical care in medical organizations with information and explanatory materials on their rights.
X. Procedure for applying sanctions
to a medical organization for violations identified during control
65. Based on Part 1 of Article 41 of the Federal Law, the amount not payable 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 a 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 refusal to pay for medical care or a reduction in payment for medical care in accordance with this Procedure.
66. The result of control in accordance with the contract for the provision and payment of medical care under compulsory health insurance and the list of grounds for refusal to pay for medical care (reduction in payment for medical care) are:
a) non-payment or reduction of payment for medical care in the form of:
exclusion of an item from the register of invoices subject to payment for volumes of medical care;
reducing the amounts presented for payment as a percentage of the cost of medical care provided for an insured event;
return of amounts not subject to payment to the medical insurance organization;
b) payment of fines by a medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality (in the event of an insured event in which defects in medical care and / or violations in the provision of medical care were identified).
67. Non-payment or reduction of payment for medical care and payment of fines by a medical organization in accordance with subparagraph b) of paragraph 66 of this section, depending on the type of identified defects in medical care and / or violations in the provision of medical care, can be applied separately or simultaneously.
68. If violations of contractual obligations are identified in relation to the volume, timing, quality and conditions of providing medical care, the insurance medical organization does not partially or fully reimburse the costs of the medical organization for providing medical care, reducing subsequent payments on the medical organization’s bills by the amount of identified defects in medical care and / or violations in the provision of medical care or requires the return of amounts to the medical insurance organization.
The amount not subject to payment based on the results of control is withheld from the amount of funds provided for payment for medical care provided by a medical organization, or is subject to return to the medical insurance organization in accordance with the agreement for the provision and payment of medical care under compulsory medical insurance.
69. For failure to provide, untimely provision, or provision of medical care of inadequate quality under an agreement for the provision and payment of medical care under compulsory health insurance, the medical organization shall pay the medical insurance organization a fine in the amount established under the specified agreement and in accordance with the list of grounds for refusal (reduction ) payment for medical care (Appendix 8 to this Procedure).
70. If in one and the same case of medical care there are two or more grounds for refusal to pay for medical care or a reduction in payment for medical care, one more significant ground is applied to the medical organization, entailing a larger amount of non-payment or refusal to pay. The amount of incomplete payment for medical services for one insured event is not summed up.
71. 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.
72. Funds received as a result of the application of sanctions to a medical organization for violations identified during control are spent in accordance with Federal Law.
XI. Appeal
medical organization, conclusion of an insurance medical 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 a 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 (Appendix 9 to this in order).
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) justification for the claim;
b) a list of questions for each disputed case;
c) materials of internal and departmental quality control of medical care in a medical organization.
74. The Territorial Compulsory Medical Insurance Fund, within 30 working days from the date of receipt of the claim, reviews 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 laws are formalized by a 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.
Changes in funding based on the results of consideration of controversial cases are carried out by the medical insurance organization no later than 30 working days (during the period of final settlement with the medical organization for the reporting period).
76. If a medical organization disagrees with the decision of the territorial fund, it has the right to appeal this decision in court.
XII. Organization of control by the territorial compulsory health insurance fund during settlements
for medical care provided to insured persons outside the constituent entity of the Russian Federation,
in the territory of which the compulsory health insurance policy was issued
77. The organization by the territorial compulsory medical insurance fund of control when making payments for medical care provided to insured persons outside the constituent entity of the Russian Federation on the territory of which the compulsory medical insurance policy was issued is carried out in accordance with sections III-V of this Procedure.
XIII. Workers,
carrying out medical and economic examination and examination of the quality of medical care
78. In accordance with Part 5 of Article 40 of the Federal Law, a medical and economic examination is carried out by a specialist expert who is a doctor who has worked in a medical specialty for at least five years and has undergone appropriate training in expert activities in the field of compulsory health insurance.
79. The main tasks of the specialist expert are:
a) monitoring the compliance of the medical care provided with the terms of the contract for the provision and payment of medical care under compulsory health insurance by establishing the compliance of the actual terms of medical care, the volumes of medical services provided for payment with the records in the primary medical and accounting and reporting documentation of the medical organization;
b) participation in organizing and conducting an examination of the quality of medical care and ensuring guarantees of the rights of insured persons to receive medical care of appropriate quality.
80. The main functions of a specialist expert are:
a) selective control of the volume of medical care for insured events by comparing actual data on medical services provided to the insured person with the procedures for providing medical care and standards of medical care;
b) selection of cases for examination of the quality of medical care and justification of the need for its implementation, preparation of documentation necessary for an expert of the quality of medical care to conduct an examination of the quality of medical care;
c) preparation of materials for the methodological framework used for the examination of the quality of medical care (procedures for the provision of medical care and standards of medical care, clinical protocols, methodological recommendations, etc.);
d) generalization, analysis of conclusions prepared by an expert on the quality of medical care, participation in the preparation of an act in the established form or preparation of an act in the established form;
e) preparation of proposals for filing claims or lawsuits against a medical organization for compensation for harm caused to insured persons and sanctions applied to the medical organization;
f) familiarization of the management of the medical organization with the results of medical and economic examination and examination of the quality of medical care;
g) generalization and analysis of control results, preparation of proposals for the implementation of targeted and thematic medical and economic examinations and examinations of the quality of medical care;
h) assessment of the satisfaction of insured persons with the organization, conditions and quality of medical care provided.
81. The examination of the quality of medical care in accordance with Part 7 of Article 40 of the Federal Law is carried out by a quality expert of medical care, who is a medical specialist with a higher professional education, a certificate of specialist accreditation or a specialist certificate, work experience in the relevant medical specialty of at least 10 years and trained in expert activities in the field of compulsory health insurance, included in the territorial register of experts in the quality of medical care (clause 84 of this section).
An expert in the quality of medical care conducts an examination of the quality of medical care in his/her main medical specialty, as determined by a diploma, a certificate of accreditation of a specialist, or a specialist certificate.
When conducting an examination of the quality of medical care, the quality of medical care expert has the right to maintain anonymity/confidentiality.
82. The main task of the quality of medical care expert is to conduct an examination of the quality of medical care in order to identify defects in medical care, including assessing the correctness of the choice of a medical organization, the degree of achievement of the planned result, establishing cause-and-effect relationships of identified defects in medical care, drawing up an expert opinion and recommendations for improvement quality of medical care in compulsory health insurance.
An expert on the quality of medical care is not involved in the examination of the quality of medical care in a medical organization with which he has an employment or other contractual relationship, and is obliged to refuse to conduct an examination of the quality of medical care in cases where the patient is (was) his relative or patient, in treatment in which a quality of care expert was involved.
83. An expert on the quality of medical care when conducting an examination of the quality of medical care:
a) uses medical documents containing a description of the diagnostic and treatment process, and, if necessary, examines patients;
b) provides information about the regulatory documents used (procedures for the provision of medical care and standards of medical care, clinical protocols, methodological recommendations) at the request of officials of the medical organization in which the examination of the quality of medical care is carried out;
c) complies with the rules of medical ethics and deontology, maintains medical confidentiality and ensures the safety of medical documents received for temporary use and their timely return to the organizer of the examination of the quality of medical care or to a medical organization;
d) discusses with the attending physician and the management of the medical organization the preliminary results of the examination of the quality of medical care.
84. The territorial register of medical care quality experts contains information about medical care quality experts who carry out examination of the quality of medical care as part of control in a constituent entity of the Russian Federation, and is a segment of the unified register of medical care quality experts.
The territorial register of medical care quality experts is maintained by territorial compulsory health insurance funds in accordance with clause 9 of part 7 of article 34 of the Federal Law on the basis of uniform organizational, methodological, software and technical principles.
Responsibility for violations in the maintenance of the territorial register of medical care quality experts lies with the director of the territorial compulsory health insurance fund.
In accordance with clause 11 of part 8 of Article 33 of the Federal Law, the Federal Compulsory Medical Insurance Fund maintains a unified register of medical care quality experts, which is a collection of electronic databases of territorial registers of medical care quality experts.
Appendix 6
to the Tariff Agreement
Regulations on formation and control
fulfilling the volume of medical care provided by medical organizations in the compulsory health insurance system
1. In accordance with Part 6 of Article 39 of the Federal Law - Federal Law “On Compulsory Medical Insurance in the Russian Federation” (as amended on January 1, 2001), paragraphs 110, 123 of the Rules of Compulsory Medical Insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation N (as amended . from 01.01.2001), payment for medical care within the framework of the territorial compulsory medical insurance program of the Rostov region is carried out on the basis of the registers of bills and invoices for payment of medical care submitted by the medical organization within the scope of provision of medical care distributed by the decision of the Commission for the development of the territorial compulsory medical insurance program (hereinafter referred to as the Commission ), formed by the Government of the Rostov region.
2. The volumes of medical care distributed by the decision of the Commission for a specific medical organization are considered as a state task for the provision of medical care in the compulsory health insurance system of the Rostov region (hereinafter referred to as the state task). Volumes of medical care that exceed the state assignment (not provided for by the standards established by the territorial compulsory medical insurance program) are medical services provided outside the territorial compulsory health insurance program and are not subject to payment from compulsory medical insurance funds.
3. State tasks are established by the Commission based on the calendar year in physical terms (in units of volumes of medical care provided for the relevant types of medical care by the territorial compulsory medical insurance program) and in cost terms within the territorial standards for the volume of medical care and amounts for payment of medical care under compulsory medical insurance, provided for in the budget of the TFOMS of the Rostov region for the corresponding period.
4. In accordance with paragraph 123 of the Rules of Compulsory Medical Insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation no, the established volume of medical care (state assignment) takes into account:
1) the number of insured persons attached to medical organizations providing outpatient medical care, and indicators of the volume of medical care provided per insured person per year, approved by the territorial program, taking into account indicators of consumption of medical care, types of medical care, conditions for the provision of medical care and medical specialties ;
2) indicators of the volume of medical care provided per insured person per year, approved by the territorial program, taking into account the profiles of departments (beds), medical specialties, types of medical care and the conditions for its provision by medical organizations that do not have attached insured persons;
3) the number of diagnostic and (or) advisory services to meet the needs of medical organizations to meet the standards of medical care and procedures for its provision for diseases and conditions in full in the absence or insufficiency of these diagnostic and (or) advisory services from medical organizations, for accounting purposes in contracts with medical organizations that provide only the specified services in accordance with the right to provide them;
4) the ratio of the volumes of medical care provided and those paid by medical insurance organizations;
5) territorial accessibility of certain types of medical care;
6) the need and possibility of introducing and developing new modern medical technologies;
7) availability of resources, including personnel, to ensure the planned volumes of medical care;
8) the patient’s right to choose a medical organization and doctor;
9) the ability to achieve optimal medical, economic and social efficiency in the use of material, technical and financial resources;
10) the ability to achieve socially significant results-oriented indicators of health care performance.
5. Medical organizations included in the prescribed manner in the territorial register of medical organizations operating in the field of compulsory health insurance form reasonable proposals on the volume of government assignments for the corresponding year. The recommended form of proposals, the procedure and specific deadlines for their submission are established by the Ministry of Health of the Rostov Region and the territorial Compulsory Medical Insurance Fund. Proposals are justified taking into account paragraph 4 of these Regulations.
Heads of municipal health authorities, chief doctors of districts, in order to coordinate the distribution of volumes of medical care in the territory of the municipality, coordinate proposals on the volume of government assignments of subordinate municipalities, as well as departmental, federal municipalities and medical organizations of other forms of ownership located on the territory of a given municipality.
6. The decision of the Commission on the distribution of the volume of medical care and financial resources (state assignments) between medical organizations is brought to the attention of insurance medical organizations and medical organizations by the Ministry of Health of the region and the territorial compulsory medical insurance fund, and is taken into account when calculating tariffs for the provision of medical care under compulsory medical insurance as planned production indicators for the volume of medical care provided by medical organizations.
The decision of the Commission on the distribution of volumes of high-tech medical care in compulsory medical insurance is communicated by order of the Ministry of Health of the Rostov Region for each medical organization named in the list of this order in cases of hospitalization. In this case, cases of hospitalization (and, accordingly, bed days) of primary care in compulsory medical insurance are taken into account separately in addition to (in addition to) the volume of provision of medical care and financial resources (state assignments). Control of distributed volumes of HFMP in compulsory medical insurance is also carried out separately.
7. The volumes allocated by the decision of the Commission for a specific medical organization are an integral part of contracts for the provision and payment of medical care under compulsory medical insurance (clause 4.1., Appendix 1 to the Model Agreement, approved by order of the Ministry of Health of the Russian Federation n). In accordance with paragraph 123 of the Compulsory Medical Insurance Rules and in accordance with the form of the Model Agreement, the volumes distributed by the decision of the Commission for the year are subject to quarterly breakdown. For this purpose, by order of the head of the Ministry of Defense, the institutional annual volumes are distributed in the context of four quarters of the year according to the profiles of departments (beds) of inpatient care and care provided in day hospitals, medical specialties of outpatient care and specialists providing paraclinical services.
Volumes for MOs and their individual divisions cannot exceed standard production indicators, taking into account the actual capacity of existing MOs and approved staffing schedules.
The quarterly breakdown of volumes should ensure the constant possibility of providing medical care under compulsory medical insurance throughout the year, taking into account its seasonality. A disproportionate quarterly breakdown that reduces the availability of medical care under the compulsory medical insurance program in certain periods of the year is not allowed (except for cases of planned closure of medical institutions for repairs and for other reasons).
In order to eliminate the discrepancy between the breakdown of government assignments and the indicators distributed by decision of the commission, draft orders of the heads of the Ministry of Defense on the breakdown of volumes are agreed upon with the Ministry of Health of the region and the Federal Compulsory Compulsory Medical Insurance Fund of the Rostov Region.
8. According to paragraph 123 of the Compulsory Medical Insurance Rules, the possibility of reasonable adjustment of volumes is provided during the year. At the same time, the plan for the first quarter cannot exceed 30% of the annual volume, for the fourth quarter cannot be less than 25% of the annual volume, and for December cannot be less than 8% of the annual volume.
8.1. Redistribution of volumes within a municipal organization between quarters of the year (changes in the quarterly breakdown) is permitted subject to the condition that there is no increase in annual volumes (in physical and value terms) and a financial and economic activity plan approved for the year. Changes are only possible for the current and subsequent quarters. Such changes are formalized by order of the head of the Moscow Region, agreed upon with the head of the municipal health authority. A copy of the order must be submitted to the Federal Compulsory Compulsory Medical Insurance Fund of the Rostov Region no later than the 1st day of the last month of the current quarter, before the adoption of adjustments to the plan of financial and economic activities of the Moscow Region. After the adoption of an adjustment to the plan of financial and economic activities, changes to the order on the distribution of government tasks are not allowed. An order marked by the Federal Compulsory Compulsory Medical Insurance Fund on its acceptance is the basis for making changes to Appendix No. 1 to contracts with medical insurance organizations. Failure to submit (untimely submission) of an order to the Federal Compulsory Compulsory Medical Insurance Fund of the Rostov Region entails the impossibility of making changes to Appendix No. 1 to contracts with health insurance organizations and, accordingly, the impossibility of taking into account changes when monitoring the implementation of government tasks.
8.2. Decisions to adjust government assignments, entailing a change in the total annual amount of funding for the Ministry of Defense, are possible if there are objectively determined reasons for such an adjustment and are the prerogative of the Commission. Proposals containing justification for the need to adjust the state assignment, agreed upon with municipal health authorities (chief doctors of the districts), are sent by the heads of the municipality to the Commission through the regional Ministry of Health and the Federal Compulsory Compulsory Medical Insurance Fund.
Objectively determined reasons for adjusting the state assignment may be reorganization, temporary closure, liquidation of municipalities (divisions of municipalities), decisions of health care authorities to change the organization of medical care, the presence of emergency situations that resulted in an increase in insurance cases under compulsory medical insurance, etc. Heads of municipalities must inform the Rostov Federal Compulsory Compulsory Medical Insurance Fund in advance region about the planned liquidation, reorganization, temporary closure of the Moscow Region (branch).
When the Ministry of Defense receives a proposal to increase the state task previously established for the current year, the regional Ministry of Health and the Federal Compulsory Compulsory Medical Insurance Fund will organize a check of the validity of such a proposal, for which they may request additional information and organize a comprehensive (including with the participation of health care organizations) medical and economic examination of the volume of medical care. If the validity of the proposal is confirmed, it is submitted to the Commission for consideration.
In case of a positive decision to increase volumes, the Commission considers the issue of the source of covering additional costs. The increase in volumes should be made within the total amount of allocations for the implementation of the territorial compulsory medical insurance program provided for in the TFOMS budget, that is, as a rule, an increase in volumes for some municipalities is carried out with a corresponding decrease for other municipalities.
In exceptional cases, if an objectively necessary increase in the state assignment cannot be made without increasing the total cost of medical services under the territorial compulsory medical insurance program, the issue of such an increase is considered by the Commission taking into account the current legislation on compulsory medical insurance.
The Commission's decision to adjust the distribution of volumes is communicated to the compulsory medical insurance participants and is the basis for making changes to contracts for the provision and payment of medical care under compulsory medical insurance.
8.4. Planning for the distribution of volumes of medical care in the compulsory medical insurance system for 2017 will be carried out within the framework of the Guidelines for the provision of information on the volumes of medical care and their financial support by members of the commission for the development of the territorial compulsory health insurance program, developed by the Compulsory Medical Insurance Fund, the Federal Compulsory Medical Insurance Fund, the medical community and the NP "National Medical Insurance". Ward". These guidelines for providing information on the volume of medical care and their financial support are used for the purpose of distributing the volume of medical care and their financial support by members of the commission for the development of the territorial compulsory health insurance program is used for the purpose of distributing volumes between medical insurance organizations and between medical organizations within territorial compulsory health insurance program until January 1 of the next year.
9. Heads of medical organizations and heads of municipal health care authorities, within the framework of their official duties, organize and manage the activities of subordinate medical organizations, ensuring the fulfillment of established government tasks.
10. In order to determine the volumes of medical care corresponding to the territorial compulsory medical insurance program, and the volumes of medical care that are not subject (according to the current legislation and agreements) to payment from compulsory medical insurance funds, within the framework of established procedures for information exchange between compulsory medical insurance participants (clause 8 of part 8 of article 33 Federal Law -FZ) monitors the actual implementation of government tasks by medical organizations.
10.1. In accordance with the general principles of the construction and operation of information systems and the procedure for information interaction in the field of compulsory medical insurance, approved by the Federal Compulsory Medical Insurance Fund (Compulsory Medical Insurance Fund order No. 79 dated January 1, 2001), verification of the compliance of the volumes of medical care presented for payment with the established state tasks is carried out by the territorial Compulsory Medical Insurance Fund in during the initial automated processing of registers at the stage of format-logical control and determination of the insurance affiliation of the insured (patients).
Checking the compliance of the volumes of medical care presented for payment with the established state tasks is carried out monthly in the context of individual conditions for the provision of medical care in natural (volume) and cost indicators.
10.2. When checking the registers of accounts for the first and second months of each quarter, the indicators recorded in the plan of financial and economic activities of the Moscow Region for the corresponding month are used as planned indicators of the state task (for comparison with actual ones). If in the registers of accounts based on the results of the first and second months of the quarter, the volumes of medical care presented for payment in physical and/or cost terms on an accrual basis from the beginning of the quarter exceed the corresponding planned indicators, such registers are recognized as having not passed the format-logical control procedure and are subject to correction by the medical organization with excluding from them volumes exceeding the state assignment (at the discretion of the medical organization). Volumes of medical care that exceed the state assignment for the first and second months of each quarter, by decision of the head of the Moscow Region, may be presented for payment in additional invoices in the next month, in which case they will be taken into account towards the fulfillment of the state assignment of the next quarter.
10.3. When checking the registers of accounts for the third month of each quarter, the indicators recorded in the order on the quarterly breakdown of the state task, in the plan of financial and economic activities and in Appendix No. 1 to the contracts for the provision and payment of medical care under compulsory medical insurance for the corresponding quarter are used as planned indicators of the state task. If in the registers of accounts based on the results of the third month of the quarter, the volumes of medical care presented for payment in natural and/or cost terms on an accrual basis from the beginning of the quarter exceed the corresponding planned indicators, such registers are recognized as having not passed the format-logical control procedure and are subject to correction by the medical organization with exclusion from of them in volumes exceeding the state assignment (at the discretion of the medical organization). Volumes of medical care that exceed the state assignment at the end of the quarter are not subject to re-invoicing for payment in the subsequent period.
11. According to the order of the Federal Compulsory Medical Insurance Fund “On approval of the procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance”, the fact of presentation for payment of cases of medical care in excess of the distributed volume of medical care, established by the decision of the Commission , is a violation that gives the health insurance organization grounds for applying financial sanctions to a medical organization (inclusion in the register of medical care that is not included in the territorial compulsory medical insurance program).
12. Information on the implementation of state tasks by medical organizations is brought to the attention of health insurance organizations and medical organizations in the format provided for in Appendix 8 to the Tariff Agreement, and is also posted in a continuous monitoring mode on the official website of the Federal Compulsory Medical Insurance Fund of the Rostov Region on the Internet (section “Control of government tasks”).
Based on the analysis of this information, the heads of medical organizations must promptly take the necessary measures to ensure that the volume of medical care provided under the territorial compulsory medical insurance program corresponds to the established state tasks.
13. In accordance with Part 9 of Article 14 of the Federal Law - Federal Law “On Compulsory Medical Insurance in the Russian Federation” (as amended on January 1, 2001), in the field of compulsory medical insurance, information support is provided to insured persons when organizing the provision of medical care to them.
13.1. Every day, no later than 09.00 hours, a medical organization (MO) providing medical care in an inpatient setting sends information to an insurance medical organization (IMO) about the fulfillment of the volume of medical care, about the number of insured persons hospitalized in a medical organization to provide medical care in an inpatient setting ( including by type of medical organizations that referred the insured person for hospitalization).
13.2. Information from the Ministry of Internal Affairs is communicated to the CMO by entering data into the monitoring portal for information support of insured persons on the website of the Federal Compulsory Compulsory Medical Insurance Fund of the Rostov Region, which is filled out in accordance with the appendix to this Regulation. The MO enters the portal using an individual login and password indicating the type of MO (hospital or outpatient clinic). If the MO provides both outpatient and inpatient medical care, then the type of MO is indicated depending on the purpose of entering the portal - inpatient for entering information about hospitalization, outpatient clinic for entering information about issued referrals for hospitalization.
13.3. The procedure for entering data into the table is as follows:
Columns 1 - 5 are filled in automatically in accordance with the structure of the MO; the data is subject to change no later than 1 business day from the date of approval of the changes.
Columns 6 - 8, columns 11, 13, 14 are filled in by medical institutions providing medical care in inpatient settings.
Column 12 is calculated and is filled in automatically only for the lines “Total by department:”, “Total by profile:”.
Column 13 is filled in by medical institutions providing medical care in inpatient settings using the line “Total by department” and is automatically summed up by the line “Total by profile”.
Columns 9 and 10 are filled in by medical institutions providing primary health care on an outpatient basis.
13.4. An insurance medical organization, on the basis of information, access to which is provided by the territorial fund, transferred by medical organizations providing medical care in inpatient settings, with which it has an agreement for the provision and payment of medical care under compulsory health insurance, summarizes and keeps records as of 09.00 hours of the day for transmitting information for each medical organization.
13.5. Every day, no later than 10:00 a.m. local time, the insurance medical organization informs the person authorized by the head of the medical organization providing primary health care on an outpatient basis to interact with the insurance medical organization on hospitalization issues (hereinafter referred to as the authorized person):
On the availability of volumes of medical care and the number of available places for hospitalization in a planned and emergency form, broken down by departments (codes) for each medical organization providing medical care in inpatient conditions, with which it has concluded an agreement for the provision and payment of medical care under compulsory health insurance ;
About hospitalized insured persons in a planned and emergency form.
13.6. In accordance with the order of the Ministry of Health and Social Development of Russia No. “On approval of the Procedure for a citizen to choose a medical organization when providing him with medical care within the framework of the program of state guarantees of free provision of medical care to citizens” (registered by the Ministry of Justice of the Russian Federation on May 21, 2012, registration No. 000) and the order of the Ministry of Health Russia N “On approval of the Procedure for a citizen to choose a medical organization (except for cases of emergency medical care) outside the territory of the constituent entity of the Russian Federation in which the citizen lives, when providing him with medical care within the framework of the program of state guarantees of free medical care” (registered by the Ministry of Justice Russian Federation March 12, 2013 No. 000) when issuing a referral for planned hospitalization, the attending physician is obliged to inform the insured person or his legal representative about medical organizations participating in the implementation of the territorial program, in which it is possible to provide specialized medical care, taking into account the waiting period for the specified type of medical care established by the territorial program.
To inform the insured person or his legal representative, the attending physician contacts an authorized person.
Application
to the “Regulations on the formation and control
fulfillment of the scope of provision of medical
assistance from medical organizations in the system
Compulsory medical insurance of the Rostov region"
Form for monitoring information support of insured persons when organizing the provision of medical care to them
Bed profile | Branch number | Name of the SMO | Number of beds | Fulfillment of MP volumes (days of hospitalization, patient days cumulatively from the beginning of the year) | Information on the number of insured persons | Availability of MP volumes (hospitalization days, patient days) | Availability of free places in the department | Sign of operation in emergency mode |
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Profile code | Profile name | hospitalized | retired | received a referral for hospitalization | in respect of which Planned hospitalization did not take place |
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planned | urgent |
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AlfaStrakhov | |||||||||||||
Maximus | |||||||||||||
RGS-Rost-Med | |||||||||||||
SOGAZ-Med | |||||||||||||
Dr. subjects of the Russian Federation | |||||||||||||
Not insured | |||||||||||||
Total by profile | |||||||||||||
Total for the department |