A commercial medical organization provides services to the population on a paid basis. The organization plans to enter into an agreement with the Compulsory Health Insurance Fund (hereinafter referred to as the MHIF), under which, after providing medical services to the population, the MHIF will reimburse the organization for the cost of the services provided.
How to reflect in accounting the provision of services for compulsory health insurance, the receipt of funds for compulsory health insurance, accounting for materials (receipt, write-off) related to the provision of services for compulsory health insurance?

Commercial medical organizations maintain accounting records in accordance with the Chart of Accounts for accounting the financial and economic activities of organizations and the Instructions for its application, approved by Order of the Ministry of Finance of Russia dated October 31, 2000 N 94n (hereinafter referred to as the Chart of Accounts, Instructions for the application of the Chart of Accounts).
Medical services provided by the organization under compulsory health insurance are reflected in accounting in the general manner, similar to services on a paid basis.
Based on the fact that the provision of medical services is the main activity of the organization, receipts (revenue) associated with the provision of such services are income from ordinary activities (clauses 2, 4, 5 of PBU 9/99 “Income of the organization”).
In accordance with clause 6 of PBU 9/99, revenue is accepted for accounting in an amount calculated in monetary terms equal to the amount of receipt of cash and other property and (or) the amount of accounts receivable (taking into account the provisions of clause 3 of PBU 9/99) .
In this case, revenue is recognized in accounting if the conditions listed in clause 12 of PBU 9/99 are met, namely:
a) the organization has the right to receive this revenue arising from a specific agreement or confirmed in another appropriate manner;
b) the amount of revenue can be determined;
c) there is confidence that as a result of a particular transaction there will be an increase in the economic benefits of the organization. Confidence that as a result of a particular transaction there will be an increase in the economic benefits of the organization exists when the organization received an asset in payment or there is no uncertainty regarding the receipt of the asset;
d) the right of ownership (possession, use and disposal) of the product (goods) has passed from the organization to the buyer or the work has been accepted by the customer (service provided);
e) the expenses that have been incurred or will be incurred in connection with this operation can be determined.
Thus, in accounting, revenue is recognized regardless of whether funds were received as payment or not (accrual method).
In accordance with the Chart of Accounts, when recognized in accounting, the amount of revenue from the provision of services is reflected in the credit of account 90 “Sales”, the subaccount “Revenue”, and the debit of account 62 “Settlements with buyers and customers” (receivables from the buyer are reflected) as of the date provision of services (clauses 5, 6.1, 12 PBU 9/99). At the same time, the cost of services provided is written off from account 20 “Main production” to the debit of account 90, sub-account “Cost of sales” (clauses 5, 16, 19 PBU 10/99 “Organization expenses”).
Taking into account the fact that the Compulsory Medical Insurance will be calculated for the services provided to the population by the Compulsory Medical Insurance Fund, in the situation under consideration, the organization should make the following accounting entries (with separate accounting of compulsory medical insurance services):
Debit 62, subaccount "Settlements for compulsory medical insurance" Credit 90, subaccount "Revenue from compulsory medical insurance services"
- income from the provision of compulsory medical insurance services is recognized;
Debit 90, subaccount "Cost of services provided under compulsory medical insurance" Credit 20, subaccount "Cost of services provided under compulsory medical insurance"
- the cost of services provided under compulsory medical insurance is written off.
The receipt and write-off of materials is reflected taking into account PBU 5/01 “Accounting for inventories” and the Guidelines for accounting of inventories, approved by Order of the Ministry of Finance of Russia dated December 28, 2001 N 119n.
In accordance with clause 5 of PBU 5/01, inventories are accepted for accounting at their actual cost, which recognizes the amount of the organization’s actual costs for the acquisition, excluding VAT and other refundable taxes (except for cases provided for by the legislation of the Russian Federation). The list of possible actual costs associated with the acquisition of inventories is contained in clause 6 of PBU 5/01.
The cost of materials is written off as a lump sum upon release for the provision of services (performance of work) and is included as expenses for ordinary activities (clauses 7, 8 of PBU 10/99).
According to the Instructions for using the Chart of Accounts, accounting for materials is carried out by organizations on account 10 “Materials”.
If the organization does not use accounts 15 "Procurement and acquisition of material assets" and 16 "Deviation in the cost of material assets", the posting of materials is reflected by an entry in the debit of account 10 "Materials" and the credit of accounts 60 "Settlements with suppliers and contractors", 20 "Main production ", 23 "Auxiliary proceedings", 71 "Settlements with accountable persons", 76 "Settlements with various debtors and creditors", etc. depending on where certain values ​​came from, and on the nature of the costs of procuring and delivering materials to the organization.
The actual consumption of materials in production or for other business purposes is reflected in the credit of account 10 “Materials” in correspondence with the accounts of production costs (selling expenses) or other relevant accounts.
In this case, we believe that the organization should make the following entries:
Debit 10 Credit 60
- materials received from the supplier are capitalized;
Debit 20, subaccount "Costs for compulsory medical insurance services" Credit 10
- the cost of materials is written off as expenses for compulsory medical insurance services.
Regarding the MHIF reimbursement of the organization for the cost of medical services provided at the expense of compulsory health insurance funds in accordance with the contract, based on the question, we believe that after the MHIF approves the report (act or other document) on the services provided (work performed), the MHIF will have a debt to the organization that the fund must pay.
In our opinion, in this case the organization will have to make the following entries:
Debit 76, subaccount "Settlements with the Compulsory Medical Insurance" Credit 62, subaccount "Settlements for the Compulsory Medical Insurance"
- reflects the amount of the MHIF debt according to the report (act, etc.);
Debit 51 Credit 76, subaccount "Settlements with the Compulsory Medical Insurance Fund"
- funds from the Compulsory Medical Insurance Fund have been deposited into the current account.

The answer was prepared by:
Expert of the Legal Consulting Service GARANT
auditor, member of the Russian Board of Auditors Liliya Fedorova

Response quality control:
Reviewer of the Legal Consulting Service GARANT
auditor, member of RSA Gornostaev Vyacheslav

The material was prepared on the basis of individual written consultation provided as part of the Legal Consulting service.

Russian citizens are guaranteed free medical care by the state. People are given a policy - a document that represents the support of the state healthcare system in the event of illness.

What does it really mean? What types of services are the clinic required to provide without additional payment, and which ones will you have to pay for yourself? Under what circumstances is a free medical examination carried out? Let's look at all the questions in detail.

About free medicine

Article 41 of the Constitution of the Russian Federation lists guarantees to citizens of the country from the state. In particular, it says:

“Everyone has the right to health care and medical care. Medical care in state and municipal health care institutions is provided to citizens free of charge at the expense of the corresponding budget, insurance premiums, and other revenues.”

Thus, the list of free medical services should be determined by the relevant government bodies, that is, the healthcare system. This happens on two levels:

• federal;
• regional

Important! The budget fund for the development of medical institutions is formed from several sources. One of them is tax revenues from citizens.

What types of services are guaranteed by the state?

By virtue of current legislation, patients are guaranteed the right to the following types of medical care:

• emergency (ambulance), including special;
• outpatient treatment, including examination;
• hospital services:
  • gynecological, pregnancy and childbirth;
  • with exacerbation of ailments, ordinary and chronic;
  • in cases of acute poisoning, in case of injury, when intensive therapy associated with round-the-clock monitoring is necessary;
• planned care in inpatient settings:
  • high-tech, including using complex, unique methods;
  • medical care for citizens with incurable illnesses.

Important! If the disease does not fall under one of the options, you will have to pay for medical services.

Medicines are provided at the expense of the budget to people suffering from the following types of diseases:

• shortening lifespan;
• rare;
• leading to disability.

Attention! A complete and detailed list of drugs is approved by government decree.

Do you need information on this issue? and our lawyers will contact you shortly.

New in legislation since 2017

Government Decree No. 1403 dated December 19, 2016 provides a more detailed breakdown of medical services provided free of charge. In particular, primary health care stands for. It is divided into subspecies. Namely the primary one:

• pre-medical (primary);
• ambulance;
• specialized;
• palliative.

Attention! As part of the program, palliative medical care has been added to the list of services provided free of charge.

In addition, the text of the document contains a list of medical specialists who are subject to the obligation to treat patients without charging money.

These include:

• paramedics;
• obstetricians;
• other health workers with secondary specialized education;
• general practitioners of all profiles, including doctors of family medicine and pediatricians;
• medical specialists from medical organizations providing specialized, including high-tech, medical care.

Attention! The document contains a list of diseases that doctors are obliged to treat free of charge.

Medical policy

A document guaranteeing the provision of care to patients is called a compulsory health insurance policy (CHI). This paper confirms that the bearer is insured by the state, that is, all the professionals listed above are obliged to provide services to him.

Important! Not only citizens of the Russian Federation have the right to take out a compulsory medical insurance policy. It is issued (for a small fee) to foreigners permanently residing in the country.

The compulsory medical insurance policy has the following semantic content:

• the citizen is guaranteed medical support;
• medical organizations perceive it as a client identifier (for it, funds from the Compulsory Medical Insurance Fund will be transferred to the hospital).

Important! The described document is issued only by licensed insurance companies. They are allowed to be changed, but not more than once a year (until November 1 of the current period).

How to get a compulsory medical insurance policy

The document is issued by the relevant companies operating within the framework of the legislation of the Russian Federation. Their ratings are regularly published on official websites, allowing citizens to make their choice.

To issue a compulsory medical insurance policy, you must provide a minimum number of documents.

Namely:

• for children under 14 years old:
  • birth certificate;
  • passport of the parent (guardian);
  • SNILS (if any);
• for citizens over 14 years old:
  • passport;
  • SNILS (if available).

Important! For citizens of the Russian Federation, the policy is valid for an indefinite period. Only foreigners are provided with a temporary document:

• refugees;
• temporarily residing in the country.

Rules for replacing a compulsory medical insurance policy

In some situations, the document must be replaced with a new one. These include the following:

• when moving to a region where the insurer does not operate;
• in case of filling out paper with errors or inaccuracies;
• if a document is lost or damaged;
• when it has become unusable (dilapidated) and it is impossible to make out the text;
• in case of change of personal data (marriage, for example);
• in case of planned updating of sample forms.

Attention! A new compulsory medical insurance policy is issued without paying a fee.

What is included in the free service under the compulsory medical insurance policy?

Clause 6 of Article 35 of Federal Law No. 326-FZ provides a complete list of free services under a medical policy provided to document holders. They are provided in:

• clinic;
• outpatient clinics;
• hospital;
• Ambulance.

Download for viewing and printing:

What can owners of a compulsory medical insurance policy expect?

In particular, patients have the right to free medical care and treatment in the following situations:

Dentists, like other professionals, are required to work with patients without pay.

They provide the following types of assistance:

• treatment of caries, pulpitis and other diseases (enamel, inflammation of the body and roots of the tooth, gums, connective tissues);
• surgical intervention;
• jaw dislocations;
• preventive actions;
• research and diagnostics.

Important! The following services are provided to children without paying a fee:

• to correct the bite;
• strengthening enamel;
• treatment of other lesions not related to caries.

How to apply the compulsory medical insurance policy

In order to organize treatment for patients, they are assigned to a clinic. The choice of medical institution is at the client's discretion.

It is defined:

• ease of visiting;
• location (near the house);
• other factors.

Important! You are allowed to change medical facilities no more than once a year. The exception is a change of residence.

How to “attach” to the clinic

This can be done with the help of the insurer (select an institution when receiving the policy) or independently.

To be assigned to a clinic, you must go to the institution and write an application there. Copies of the following documents are attached to the paper:

• ID cards:
  • passports for citizens over 14 years of age;
  • birth certificates of a child under 14 years of age and passports of the legal representative;
• compulsory medical insurance policy (the original is also required);
• SNILS.

Important! Citizens registered in another region can be legally denied access to a clinic if the institution is overcrowded (the maximum number of patients has been exceeded).

In case of refusal, it should be requested in writing. You can complain about a medical institution to the Ministry of Health of the Russian Federation or Roszdravnadzor.

Visit to the doctor

In order to get help from a specialist, you need to make an appointment with him through the reception desk. This department issues admission vouchers. The terms and rules for registration and patient services are established at the regional level. They can be found in the same registry.

In addition, the insurer is required to provide this information to clients (you need to call the number indicated on the policy form).

For example, in the capital the following rules apply for providing patients with medical services:

• referral to an initial appointment with a therapist or pediatrician - on the day of treatment;
• voucher for medical specialists - up to 7 working days;
• carrying out laboratory and other types of examinations - also up to 7 days (in some cases up to 20).

Important! If the clinic is unable to meet the patient’s needs, he should be referred to the nearest institution that provides the necessary services under the compulsory medical insurance program.

Ambulance

All people in the country can use emergency medical services (compulsory medical insurance is not required).

There are standards regulating the activities of ambulance teams. They are:

• The ambulance service responds to emergency calls within 20 minutes when there is a threat to people's lives:
  • accidents;
  • wounds and injuries;
  • exacerbation of the disease;
  • poisoning, burns and so on.
• emergency assistance arrives within two hours if there is no threat to life.

Important! The decision about which team will respond to a call is made by the dispatcher, based on the client’s information.

How to call an ambulance

There are several options for seeking emergency medical help. They are:

1. From a landline phone, dial 03.
2. By mobile connection:
   • 103;

Important! The last number is universal - 112. This is the coordination center for all emergency services: emergency services, fire, emergency and others. This number works on all devices if there is a network connection:

• with zero balance;
• with a missing or blocked SIM card.

Ambulance Response Rules

The service operator determines whether the call is justified. The ambulance will arrive if:

• the patient has signs of an acute illness (regardless of its location);
• there was a catastrophe, a mass disaster;
• information about an accident has been received: injuries, burns, frostbite, and so on;
• disruption of the functioning of the main body systems, life-threatening;
• if labor or termination of pregnancy has begun;
• the neuropsychiatric patient's disorder threatens the lives of other people.

Important! The service goes to children under one year of age for any reason.

Calls caused by the following factors are considered unreasonable:

• patient's alcoholism;
• non-critical deterioration in the condition of a clinic patient;
• dental diseases;
• carrying out procedures in the order of planned treatment (dressings, injections, etc.);
• organization of document flow (issuing sick leave, certificates, drawing up a death certificate);
• the need to transport the patient to another place (clinic, home).

Attention! The ambulance provides only emergency assistance. May transport patient to inpatient facility if necessary.

Where to file complaints against doctors

If conflict situations arise, rude treatment, or insufficient level of services provided, you can complain to the doctor:

• chief physician (in writing);
• to the insurance company (by telephone and in writing);
• to the Ministry of Health (in writing, via the Internet);
• The prosecutor's office (also).

Attention! The period for consideration of a complaint is 30 working days. Based on the results of the inspection, the patient is required to send a reasoned response in writing.

If necessary, the treating doctor can be changed to another specialist. To do this, you should write an application addressed to the head physician of the hospital. However, it is allowed to change specialists no more than once a year (except in cases of relocation).

Dear readers!

We describe typical ways to resolve legal issues, but each case is unique and requires individual legal assistance.

To quickly resolve your problem, we recommend contacting qualified lawyers of our site.

Last changes

On May 28, 2019, new compulsory health insurance rules came into force, which provide for the introduction of uniform policies (paper or electronic format) in Russia. In this case, there is no need to replace a previously issued policy. In addition, if it is technically possible to unambiguously identify the insured person in the unified register of insured persons, then instead of a compulsory medical insurance policy, it is allowed to present a passport (Order of the Ministry of Health of Russia dated February 28, 2019 No. 108n “On approval of the Rules of Compulsory Medical Insurance”).

The new Rules provide for stricter control over compliance with the rights of the insured, as well as close electronic interaction between the territorial Compulsory Medical Insurance Fund, insurance organizations and medical organizations:

• Every year, before January 31, clinics will have to report to the Federal Compulsory Compulsory Medical Insurance Fund (through a single portal) the number of those enrolled, the number of persons under dispensary observation, plans and schedules for medical examinations/dispensary examinations with a quarterly/monthly breakdown by therapeutic areas; work schedules);
• clinics every weekday before 9 am must report (via the TFOMS portal) on insured persons who have undergone a medical examination, as well as on persons undergoing medical examination;
• Medical organizations, medical insurance organizations (IMO) and TFOMS will exchange information every day in electronic form on the TFOMS portal: hospitals must update data on the implementation of volumes of medical care, free beds, accepted/rejected patients by 9 am; clinics update information about hospital referrals issued yesterday by 9 a.m.; medical organizations providing specialized, including high-tech, medical care post information about patients who received a telemedicine consultation, and the CMO is obliged to monitor the implementation of recommendations received from doctors of the National Medical Research Center, and has the right to conduct a face-to-face examination within the next 2 working days ;
• Regardless of the above-mentioned interaction, the health care provider every day no later than 10 am informs hospitals about patients sent to such hospitals the day before, and also every day no later than 10 am informs medical organizations about the number of free beds in the context of profiles/departments, about patients whose hospitalization did not take place;
• The CMO, using data from the TFOMS portal, checks during the working day whether patients were correctly referred to specialized medical organizations. If the hospitalization was untimely and not according to the profile, the health care provider must file a complaint with the head physician of the offending medical organization and the regional Ministry of Health, and, if necessary, take action and transfer the patient;
• insurance representatives of the health insurance company received a wide range of responsibilities - working with citizens’ complaints, organizing examinations of the quality of medical care, informing and accompanying them during the provision of medical care, inviting them to medical examination, monitoring its completion, creating lists of “persons for medical examination” and lists of citizens who fell under medical examination observation;
• patients will be able to see when and what medical services were provided to them, and at what cost: in their personal account on the government services portal or through the Federal Compulsory Compulsory Compulsory Medical Insurance (TFOMS) - by authorization in the Unified Identification and Logistics Authority;
• For cancer patients, the health insurance company undertakes to create (on the TFOMS portal) an individual history of insurance claims (based on registers and accounts) throughout all stages of medical care.

The updated Compulsory Medical Insurance Rules directly impose on the CMO the obligation to carry out pre-trial protection of the rights of insured persons. When they file complaints about poor-quality medical care or charging for services under the compulsory medical insurance program, the CMO registers written appeals, conducts a medical and economic examination and an examination of the quality of medical care.

Our experts monitor all changes in legislation to provide you with reliable information.

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The program in which a company operating in the field of compulsory and voluntary health insurance can keep records is specific and not standard. Specialists from the automation department of ZAO Business Technology tell us what techniques made it possible to adapt 1C:Accounting 8 to the needs of the insurance company ROSNO-MS.

Reference OJSC ROSNO-MS is a subsidiary of OJSC ROSNO, one of the largest Russian universal insurance companies, providing a full range of services in the insurance market. The main activity of OJSC "ROSNO-MS" is compulsory medical insurance (CHI). Some branches provide voluntary health insurance (VHI) services. The company has more than 50 branches located throughout Russia. One of the features of the activities of the branches is that each has its own nuances in working with local territorial compulsory health insurance funds (TFOMS). The fact is that in these funds there is no strict vertical structure and accounting methods. As a result, problems arise in the compatibility of accounting and settlement mechanisms in branches of different regions. This is especially acute at the stage of collecting and combining information when drawing up consolidated reporting in the parent organization.

The main goal in developing a solution for OJSC ROSNO-MS was to ensure data consolidation through the maximum possible standardization of accounting functions and the use of classifiers common to all branches. At the same time, the least attention was paid to calculation tasks, since they have more differences than similarities in methods, and they have an indirect influence on the formation of reporting information, and rather serve the purpose of simplifying the work.

Accounting for activities in the field of health insurance has a number of significant differences from accounting in a conventional self-supporting organization.

These are the features of the chart of accounts, methods of conducting mutual settlements, accounting for costs and determining financial results, and specialized forms of regulated reporting.

The "Enterprise Accounting" configuration on the "1C:Enterprise 8" platform was chosen as the basis for developing the system. The initial changes affected the chart of accounts of a medical insurance organization, which has a number of additional accounts for accounting for insurance operations and provides for additional sub-accounts for maintaining records for different types of activities: compulsory and voluntary medical insurance.

Table 1 shows a fragment of the chart of accounts reflecting these changes.

To account for mutual settlements between the insurance organization and the TFOMS, additional documents have been developed:

• “Calculation of insurance payments for compulsory medical insurance” (see Fig. 1);
• “Receipt of insurance payments for compulsory medical insurance” (see Fig. 2).

Rice. 1

Rice. 2

When automatically filling out the tabular part, the balances of account 77 are analyzed in the context of the analytics “Purpose of insurance payments” and “Period”.

In addition, it is possible to distribute the actual payment amount in proportion to the balances.

The ability to download a document from a Client Bank file has been implemented.

To account for mutual settlements between the insurance organization and medical institutions, the following documents were developed:

1. “Insurance expenses” - for paying bills of medical institutions and issuing advances to health care facilities for the provision of medical services. The document generates postings Debit 22 Credit 51 or Debit 60.11 Credit 51 in the case of an advance payment. It is possible to fill out the tabular part with the remaining debt to the medical institution. The procedure for uploading documents to the Client-Bank system has been implemented.
2. "Invoice" - to reflect the fact of provision of medical services.
   The document generates entries for offsetting advances (if any) issued to medical institutions (Debit 22 Credit 60.11) and records the amount of services provided.
3. "Expertise report" - to take into account penalties.
   Let's look at a clear example demonstrating the operation of the documents in this block.

Example

In January, an advance payment of 1,000 rubles was transferred to health care facilities. and the services rendered were taken into account in the amount of 900 rubles. (at the end of the month the advance balance is 100 rubles).
In February, an advance payment of 1,000 rubles was also transferred to health care facilities. and services provided in the amount of 1,500 rubles are taken into account. (an advance payment in the amount of 1,100 rubles was written off and a debt of 400 rubles arose to the health care facility at the end of the month).
In March, an examination of the services provided was carried out and penalties in the amount of 100 rubles were assessed. on two invoices. As a result, the debt to the health care facility became equal to 200 rubles. (400 rubles - 2 x 100 rubles).
Funds in the amount of 1,000 rubles were transferred to the hospital account. (200 rubles to cover the debt and 800 rubles in advance).

The postings generated by the documents for this example are shown in the table.

Table

	Document	Used wiring			Mutual settlements with health care facilities				A comment
				Transaction amount, rub.
	Insurance costs No. 1 (1,000 rub.)
	Health care invoice No. 1 (900 rub.)								Crediting the advance for the amount of the SF, the balance of the advance is 100 rubles.
	Insurance costs No. 2 (1,000 rub.)								Advance, advance balance 1,100 rubles.
	Health care invoice No. 2 (RUB 1,500)								Settlement of advance payment, debt to health care facilities 400 rubles.
	Examination report for SF No. 1 (100 rub.), CMO share 10%								Redistribution of the insurance payment to the share of the insurance company in penalties under the financing item
	Examination report for the Federation Council No. 2 (100 rub.), CMO share 10%
	Insurance costs No. 3 (1,000 rub.)								Final payment made

Postings for example

For the correct formation of the financial result, the “Month Closing” document has been revised. All regulatory procedures of the revised document generate postings in accordance with the accounting policies of the insurance organization.

To combine data in a single information base, mechanisms for exchanging reference and accounting information were implemented, as a result of which the parent organization was able to receive accounting data from branches for analysis and generation of reports. The problems of data heterogeneity in branches were solved by organizing unified classifiers and directories (cost items, other income and expense items, reserves, etc.). This made it possible to combine information from branches in the parent organization and build consolidated reports.

According to current legislation, patients have the right to equal access and receive medical care at the expense of compulsory medical insurance. Although usually, when talking about compulsory medical insurance services, we mean state clinics, it is also possible to receive expensive procedures under compulsory medical insurance in private clinics. The inclusion of private clinics in the compulsory medical insurance system became possible thanks to changes in the Federal Law on Health Insurance in 2010 - they were able to receive reimbursement for the costs of serving patients from the fund.

What services are available in private clinics operating in the compulsory medical insurance system?

The task of private clinics providing treatment under the compulsory medical insurance system is to assist state budgetary healthcare. Thanks to the work of private clinics, the problem of having specialized specialists is solved, or patients are given the opportunity to undergo technologically complex procedures, which public clinics are not always able to provide. A referral for such assistance is issued by a local physician (therapist) at a territorial clinic. To receive a free service in a private clinic (paid for from the compulsory medical insurance fund), patients must present a referral from their therapist and an insurance policy.

In order for a clinic to be able to obtain permission to work under compulsory medical insurance, it is necessary to send a notification application to the regional fund, which is necessary for entering it into the register.

IMPORTANT!
The application must be submitted before September 1, preceding the start of the year of future work in the field of compulsory medical insurance. At the same time, the regional fund cannot refuse medical institutions and not include them in the register of medical institutions.

After a private clinic is included in the list of commercial medical organizations collaborating with the compulsory medical insurance system, it can provide medical services to all citizens who have entered into compulsory medical insurance contracts to the extent determined by the territorial compulsory medical insurance program.

IMPORTANT!
If your private clinic cooperates with the compulsory medical insurance system, it is obliged to inform patients about the full list of types of medical care provided free of charge. This list should be as accessible as possible - be in a visible place at the clinic’s reception desk, and be in a prominent place on the clinic’s website. If this principle is violated, a complaint may be filed against the clinic to Roszdravnadzor, since the lack of such information being available is an administrative offense.

What checks await clinics working with compulsory medical insurance?

If private clinics are going to cooperate with compulsory medical insurance, then they must be prepared for fairly strict quality control of the medical services provided by these clinics. The following points are controlled:

• registers are checked for payment for services provided by the clinic;
• economic and medical examination is carried out;
• The quality of medical care provided by the clinic is checked among patients who seek help. Up to 8% of patients from the total number of those receiving assistance can be checked.

If a clinic is found to have violated laws, penalties may apply.

On the financing of private clinics operating under compulsory medical insurance

Private clinics operating under compulsory medical insurance, receive funds from the federal fund of the medical insurance company to cover the state order of compulsory medical insurance (the number of those patients who received medical care under the program). The insurance company, within the framework of the tariffs established by the program, reimburses from compulsory medical insurance funds:

• remuneration of clinic medical staff;
• medications and materials spent by the clinic, including dressings and consumables;
• clinic utility costs;
• funds spent on medical equipment.

What documents should a patient provide to a private clinic to provide medical care under compulsory medical insurance?

Ekaterina Tyulkina, director of the medical service of the clinic of OJSC “Medicine”, doctor of medical sciences.

About company. The Clinic of OJSC "Medicine" is a medical center that provides patients with comprehensive high-tech medical care.

The opportunity for private clinics to participate in the program of providing state guarantees in the Russian Federation, in particular, in programs within the framework of compulsory medical insurance, appeared with the release of Federal Law No. 326 of November 29, 2010 “On compulsory health insurance in the Russian Federation.” The procedure for a medical organization, including a private one, to submit an application or notification for participation in the program is presented in detail on the websites of territorial compulsory medical insurance funds (MHIF). In particular, for frequent clinics located in Moscow - on the website of the Moscow City Compulsory Medical Insurance Fund.

A private medical organization, like a public one, has the right to choose services from the list of types of medical care in which it wants to participate.

Our clinic has been participating in a cooperation program with compulsory medical insurance for several years now. Although here it would be more correct to talk not about expensive services, but about the provision of high-tech medical care.

For example, now we provide high-tech medical care within the framework of compulsory medical insurance in the following areas:

• Positron emission computed tomography (PET/CT). Such studies are carried out seven days a week, almost in two shifts, from 9.00 to 20.00. The results will be given to patients undergoing the study within two hours after the study;
• Single-photon emission computed tomography (SPECT) is a nuclear medicine procedure that allows you to diagnose the functional state of various organs and their pathology by obtaining three-dimensional images, studies are carried out in the clinic 7 days a week;
• Enhanced external counterpulsation (EECP) – for patients with certain indications. The programs are very interesting, they are performed by specially trained cardiologists;
• In vitro fertilization (IVF) programs.

Surgical care is provided in the following areas:

• bladder diseases - transurethral resection of the bladder for bladder tumors;
• kidney resection – nephrectomy for kidney tumors;
• surgical treatment of complicated cataracts;
• surgical treatment of melanoma. The clinic employs unique specialists who have specialized in these types of surgical treatment in foreign clinics, in particular in Israel;
• surgical treatment of the thyroid gland – resection of the thyroid gland for thyroid tumors;
• laparoscopic cholecystectomy, hernia repair and plastic surgery;
• radiofrequency ablation of varicose veins.

The operations are carried out in the clinic’s multidisciplinary hospital, which has 4 smart operating rooms, an intensive care unit and a paid department. These are fast tracks - quick additional examination (if necessary), surgical treatment and discharge of the patient. In the postoperative period, we offer patients the opportunity for rehabilitation and recovery, but according to individual programs.

All of the above medical assistance programs apply to all residents of the Russian Federation, i.e., there can be a referral from any region of Russia.

Another type of high-tech care that we provide to patients is radiation therapy. So far, it is provided only to Moscow cancer patients and is included by the Moscow government in the program of high-tech medical care offered in addition to the basic program according to the list of compulsory medical insurance services.

The procedure for referral to receive medical care within the framework of compulsory medical insurance in a private clinic is determined by documents of the Ministry of Health of the Russian Federation and the Moscow Department of Health.

For example, Muscovites, in order to undergo a PET/CT examination, will need to have the following list of original documents on hand:

• patient's identification document;
• a valid compulsory medical insurance policy issued for the patient;
• SNILS.

In addition to the documents, the patient sent to undergo this procedure must have with him the following originals of the results of his tests:

• referral for PET/CT with FDG in the form of Order No. 477 dated July 13, 2018 and the list of nosologies specified in the appendix to Order No. 477 dated July 13, 2018;
• the result of a blood test for endogenous creatinine (the period of the test must be no later than 21 days at the time of the study);
• In addition to the originals, the patient will need the following list of copies of test results and statements that will help create and evaluate a complete picture of the patient’s disease and the treatment he received:

1. extracts from the place of last treatment in a hospital (if the patient was in hospital);
2. analysis data of histology studies (if available);
3. data from CT and MRI studies previously performed by the patient;
4. data from PET/CT studies done earlier. You must also provide a disk with the study (if available).

And to take part in the IVF program, you need:

• referral from the attending obstetrician (gynecologist) in form No. 57;
• passport, SNILS, compulsory medical insurance policy (originals and copies of these documents);
• an extract from the patient’s medical record, issued by an obstetrician (gynecologist) working at his place of residence. Then you will need an extract from the medical documentation, which must be prepared by the attending physician. It should contain: information about the diagnosis of the disease, data about the patient’s health status, information about the diagnostic and treatment methods used. It should also contain recommendations on whether it is necessary and possible to carry out an IVF procedure in this case.

TFOMS monitors the volume, timing, quality and conditions of medical care provided under compulsory medical insurance, as well as the intended use of compulsory medical insurance funds. Violation of the procedure for providing medical care by health care institutions leads to the fact that the medical insurance organization does not partially or fully reimburse them for the costs of providing it, reducing subsequent payments on bills by the amount of identified defects in medical care.

In the article we will talk about how to restore compulsory medical insurance funds that are subject to return (restoration) based on the results of control measures.

Payment for primary health care, including preventive care, emergency medical care (with the exception of sanitary aviation evacuation carried out by aircraft), specialized, including high-tech, medical care provided by medical institutions, is made based on the established tariff within the program Compulsory medical insurance. According to paragraph 7 of Art. 35 of the Law on Compulsory Health Insurance, the structure of the tariff for payment of medical care includes:

• payroll costs and accruals;
• expenses for making other payments;
• costs for the purchase of medicines, consumables, food, soft equipment, medical instruments, reagents and chemicals, and other supplies;
• expenses for paying the cost of laboratory and instrumental studies conducted in other institutions (if the medical organization does not have a laboratory and diagnostic equipment);
• costs of catering (if there is no organized catering in the medical institution);
• expenses for payment for communication services, transport, utilities, works and services for property maintenance;
• expenses for rent for the use of property, payment for software and other services;
• expenses for social security of employees of medical organizations established by the legislation of the Russian Federation;
• other expenses;
• expenses for the acquisition of fixed assets (equipment, production and household inventory) worth up to 100,000 rubles. for a unit.

It should be noted that in accordance with parts 3 – 5 of Art. 36 of the Law on Compulsory Health Insurance, the standard for financial support of the territorial compulsory medical insurance program may exceed the standard established by the basic compulsory medical insurance program. This happens when it is established:

• additional volume of insurance coverage for insured events provided for by the basic compulsory medical insurance program;
• a list of insurance cases, types and conditions of medical care in addition to those established by the basic compulsory medical insurance program.

If an additional volume of insurance coverage is established for insured events provided for by the basic compulsory medical insurance program, the territorial compulsory medical insurance program determines its list of areas for using compulsory medical insurance funds.

Medical organizations in accordance with clause 5, part 2, art. 20 of the Law on Compulsory Health Insurance are required to use compulsory medical insurance funds received for medical care provided in accordance with compulsory medical insurance programs.

When territorial compulsory medical insurance funds and insurance organizations conduct inspections, facts of misuse of compulsory medical insurance funds by medical organizations, facts of violation of the volume, timing, quality and conditions of medical care may be revealed. Based on the results of control measures, a decision may be made on the return (restoration) of compulsory medical insurance funds by the medical institution. Inappropriate spending of compulsory health insurance funds can also be detected during internal control measures. In this case, so that the inspectors do not force the institution to return such amounts to the budget, it restores them independently.

Monitoring the provision of medical care within the framework of compulsory medical insurance programs

The procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory medical insurance was approved by Order No. 230 of the Federal Compulsory Medical Insurance Fund dated December 1, 2010 (hereinafter referred to as Procedure No. 230). In paragraph 6 of Order No. 230, several types of control are highlighted (we will display them below in the form of a diagram).

Application of sanctions to a medical organization for violations identified during control

The rules for applying sanctions to medical institutions are established in clauses 65 - 72 of Order No. 230. From the provisions of clause 66 it follows that the results of control in accordance with the contract for the provision and payment of medical care under compulsory medical insurance and the list of grounds for refusing to pay for medical care (reducing it payment) are:

1) 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 payable to the medical insurance organization;

2) payment of fines by a medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality(for an insured event in which defects in medical care and (or) violations in its provision were identified).

We propose to show below in the form of a table how the results of control measures are applied to medical institutions.

Name of control result	Explanations on the application of the control result	Point of Order No. 230
Non-payment or reduction of payment for medical care	Depending on the type of identified defects in medical care and (or) violations during its provision, they can be applied separately or simultaneously
Payment of fines by medical organizations
Violation of contractual obligations regarding the volume, timing, quality and conditions of medical care	The medical insurance organization does not partially or fully reimburse the medical organization's costs 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 during its provision, or requires the return of the 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 contract for the provision and payment of medical care under compulsory medical insurance.
Failure to provide, untimely provision or provision of medical care of inadequate quality	The medical organization pays a fine in accordance with the list of grounds for refusing to pay (reducing payment) for medical care
The presence in the same case of medical care of two or more grounds for refusing to pay for it or reducing payment for medical care	One (the most significant) basis is applied to a medical organization, which entails a larger amount of non-payment or refusal to pay for medical care. The amount of incomplete payment for medical services for one insured event is not summed up
Compensation to the insured person for harm caused by the fault of a medical organization	Payment of fines by a medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality does not exempt it from compensating the insured person for harm caused due to the fault of the medical organization, in the manner established by the legislation of the Russian Federation.

Accounting for the return of compulsory medical insurance funds by a medical institution

In accordance with the budget legislation of the Russian Federation, the return of compulsory medical insurance funds is subject to accounting under the budget classification code 000 1 13 02999 09 0000 130 “Other income from compensation of costs of the budgets of territorial compulsory health insurance funds.” At the same time, the return of funds determined by the re-examination act by budgetary (autonomous) medical institutions should be reflected as a decrease in income received from insurance medical organizations, regardless of the period of their receipt. At the same time, the return of these funds by federal government medical institutions is reflected as expenses under Article 290 “Other expenses” of KOSGU (FFOMS Letter No. 1621/21-1/i dated March 21, 2014).

The procedure for maintaining accounting (budget) records of TFOMS and state (municipal) medical institutions is established by instructions No. 157n, 162n, 174n, 183n. Therefore, operations to return and restore funds must be reflected in accounting in accordance with the standards of these instructions.

Please note that according to the Instructions on the procedure for applying the budget classification of the Russian Federation, approved by Order of the Ministry of Finance of the Russian Federation dated July 1, 2013 No. 65n, income from the provision of medical services provided by recipients of federal budget funds to persons insured in the medical insurance system is reflected under Article 130 “Income from provision of paid services (work)" KOSGU.

Let us give examples of how the results of control measures are reflected in the accounting accounts.

Example 1

For violation of the conditions for providing medical care to insured citizens according to the inspection report, the budgetary medical institution was obliged to return funds in the amount of 15,000 rubles to the insurance medical organization.

Operations for the return of funds will be reflected in the accounting accounts as follows:

Example 2

For the provision of medical care of inadequate quality within the framework of the compulsory medical insurance program, a budgetary medical institution was held liable in the form of a fine in the amount of 3,000 rubles.

Transactions for calculating a fine will be reflected in the institution’s records as follows:

Next, we will give an example of reflecting in the accounting accounts the return of amounts of misappropriation of compulsory medical insurance funds to budget revenue, but first we note the following. The procedure for recording transactions for the return of compulsory health insurance funds to the budget in the accounting accounts is explained in the FFOMS Letter No. 02-06-10/4496 dated October 26, 2012. In it, officials propose to reflect the return to the budget of compulsory medical insurance funds spent for purposes other than their intended purpose, as follows:

In our opinion, the return to the budget of amounts of misappropriation of funds should be reflected not as stated in the FFOMS Letter No. 02-06-10/4496, but as a decrease in the institution’s income, while subsequent payments received from the medical insurance organization will be less for the refund amount.

Example 3

Based on the results of the audit, misuse of compulsory health insurance funds was established. The budgetary institution was obliged to return to the budget compulsory medical insurance funds spent for purposes other than their intended purpose. Let's assume that the refund amount is RUB 5,000.

Operations for the return of funds will be reflected in the accounting accounts in the same way as was shown in example 1:

At the end of the article, we will draw the following conclusions:

• medical institutions are required to use compulsory medical insurance funds received for medical care provided in accordance with compulsory medical insurance programs;
• During control activities, the institution may be required to return compulsory medical insurance funds to the medical insurance organization. Typically, such a penalty is imposed if a medical institution violates contractual obligations regarding the volume, timing, quality and conditions of providing medical care within the framework of the compulsory medical insurance program, or misuse of compulsory medical insurance funds;
• the return of compulsory medical insurance funds is reflected in the accounting accounts of the institution as a decrease in the amount of income accrued according to activity code 7 with a subsequent decrease in payments from the medical insurance organization by this amount;
• In addition to the return of compulsory medical insurance funds based on the results of control activities, the institution may have an obligation to pay fines and penalties.

Federal Law of November 29, 2010 No. 326-FZ “On Compulsory Health Insurance in the Russian Federation.”

Re-examination is a repeated examination of the quality of medical care, which can be carried out in parallel or sequentially in relation to the first examination using the same method, but by a different expert (clause 39 of Procedure No. 230).

Instructions for the application of the Unified Chart of Accounts for public authorities (state bodies), local governments, management bodies of state extra-budgetary funds, state academies of sciences, state (municipal) institutions, approved. By Order of the Ministry of Finance of the Russian Federation dated December 1, 2010 No. 157n.

Instructions for using the Chart of Accounts for Budget Accounting, approved. By Order of the Ministry of Finance of the Russian Federation dated December 6, 2010 No. 162n.

Instructions for the use of the Chart of Accounts for accounting of budgetary institutions, approved. By Order of the Ministry of Finance of the Russian Federation dated December 16, 2010 No. 174n.

Instructions for the use of the Chart of Accounts for accounting of autonomous institutions, approved. By Order of the Ministry of Finance of the Russian Federation dated December 23, 2010 No. 183n.

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