List of violations in the activity of the medical insurance organization. Interaction between an insurance medical organization and a medical institution. V. Registration of the inspection report

State medical institutions provide medical and pharmaceutical assistance at the expense of the CHI funds in the amount and on conditions that correspond to the CHI programs. Control over the targeted use of CHI funds is carried out by the territorial CHI fund (TFOMI) through inspections. The article discusses the violations that are revealed during their implementation.

The legal relationship between a health care institution, an insurance medical organization and a TFOMI in the CHI system is regulated by Federal Law No. 326-FZ of November 29, 2010 "On Compulsory Medical Insurance in the Russian Federation" (hereinafter - Federal Law No. 326-FZ). The norms of the aforementioned Law require a health care institution to spend the CHI funds to pay for medical care for the intended purpose.

Control over the use of extra-budgetary funds of compulsory medical insurance is carried out by the TFOMI for the constituent entities of the Russian Federation in accordance with the Order of the FFOMS dated 04.16.2012 N 73, which approved the Regulation on control over the use of compulsory medical insurance funds by medical organizations (hereinafter - Regulation N 73).

In accordance with clause 15 of Regulation N 73, four areas of the use of funds received by medical organizations are subject to verification, the list of which includes the use of funds to ensure the implementation of the territorial CHI program.

How is CHI funds checked?

According to clause 4 of Regulation N 73, inspections are carried out at the location of the medical organization (or at the place where it actually operates). These include:

- a comprehensive audit, in which a set of issues related to the use of compulsory medical insurance funds for a certain period of the activity of a medical organization is considered;

- thematic check, in which certain issues related to the use of CHI funds are considered;

- control check, which considers the elimination of violations and shortcomings by a medical organization in the use of compulsory medical insurance funds, previously identified during a comprehensive or thematic check.

The inspections are carried out in accordance with the plan approved by the director of the territorial fund (scheduled inspections). The frequency of scheduled inspections is established taking into account the possibility of full coverage of issues and periods of activity of medical organizations in the field of compulsory medical insurance, but at least once every two years. Scheduled due diligence checks are carried out no more than once a year.

The territorial fund may carry out unscheduled inspections. Unscheduled inspections of the use of compulsory medical insurance funds are carried out by decision of the director of the territorial fund on the basis of submissions from control bodies, complaints and applications of citizens, etc.

Checking the use of CHI funds can be carried out in a continuous or selective way (clause 9 of Regulation N 73). Note that the continuous method consists in carrying out a control action with respect to the entire set of financial, accounting, reporting and other documents related to one issue of the verification program. As for the selective method, in this case, documents related to one issue of the verification program are studied. The size of the sample and its composition are determined by the head of the commission (working group) in such a way as to ensure the possibility of assessing the issue under study of the verification program.

When checking the use of CHI funds, the following are checked:

- the correctness of the reflection in the accounting registers of transactions with CHI funds;

- correctness of reflection of income and expenses in accordance with the current budget classification;

- compliance with the procedure for conducting cash transactions and accounting for cash (in terms of compulsory medical insurance funds);

- the timeliness of the posting of the CHI cash coming from the bank and other sources, as well as their intended use;

- the availability of supporting documents and the reliability of the data contained in them, which are the basis for writing off cash expenses, the legality of expenses incurred in terms of compulsory medical insurance funds, ensuring the safety of funds.

What documents and expenses are subject to control?

As noted above, there are four main areas of expenditure of MHI funds that are subject to verification. Let us dwell only on the first of them - on the verification of the CHI funds that go to financially support the implementation of the territorial CHI program.

Note that in accordance with clause 16 of Regulation N 73, the control measure carried out by the TFOMI includes checking compliance with the requirement for keeping separate accounting for transactions with CHI funds:

- by type of medical care;

- by the structure of the tariff for paying for medical care.

Checking the costs included in the tariff structure includes (clause 17.2 of Regulation N 73):

1) verification of labor costs and charges for labor payments. During the control event, all documents confirming the validity of the payments made will be checked:

- staffing table, tariff lists, documents confirming the qualifications of specialists;

- work schedules of structural divisions and employees;

- orders for personnel;

- labor agreements;

- collective agreement;

- regulation on remuneration;

- primary accounting documents for payroll, payment of taxes and insurance premiums established by the legislation of the Russian Federation;

2) verification of expenses for the purchase of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, other material supplies, for payment of the cost of laboratory and instrumental studies carried out in other institutions. Verification of the use of funds for these purposes is carried out by checking the primary documents confirming the legality of banking operations, including contracts for the supply of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, and other inventories. Checked:

- reasonableness of prices when purchasing goods (works, services) at the expense of compulsory medical insurance funds;

- observance of delivery and payment terms, compliance of the amounts specified in the contracts with the actual expenses incurred;

- Timeliness, completeness and correctness of the posting of medicines and consumables, food products, soft inventory, medical instruments, reagents and chemicals, other inventories;

- the procedure for storing, recording and writing off medicines, consumables, food products, soft inventory, medical instruments, reagents and chemicals, and other inventories;

- availability of separate accounting of medicines purchased at the expense of compulsory medical insurance funds and funds received by a medical organization from other sources.

The analysis of purchased medicines is carried out (the availability of expired medicines is reflected).

Studied:

- materials of an inventory of property and financial obligations, carried out by a medical organization;

- availability, duration and size of accounts receivable and payable with suppliers of goods and services at the expense of compulsory medical insurance;

- Timeliness of collection of accounts receivable and repayment of accounts payable, mutual reconciliation in settlements with suppliers;

- the correctness of the accounting of these calculations, the timeliness of the collection of the amounts of identified shortages and theft of the CHI funds, material assets acquired at the expense of the CHI funds, as well as losses from damage to these valuables attributed to the perpetrators.

What violations are revealed during inspections carried out by TFOMI?

We bring to your attention disputes in which certain types of violations revealed during inspections were considered.

Implementation of expenses not included in the territorial CHI program. Medical organizations in accordance with paragraph 5 of part 2 of Art. 20 of Federal Law N 326-FZ are obliged to use the CHI funds received for the provided medical care, in accordance with the CHI programs. When conducting inspections of the TFOMS, cases are revealed when the payment of expenses for the provision of medical care to citizens of the Russian Federation is not carried out at the expense of the source that is intended for their financing. As an example, we will give the Resolution of the FAS ZSO dated 04/14/2014 N A75-3259 / 2013, in which the essence of the detected violation is as follows. The medical institution, in violation of tariff agreements and the terms of contracts, allowed the misuse of compulsory medical insurance funds, which manifested itself in the payment of the cost of equipment, furniture and equipment repairs not provided for in the tariff agreements, as well as in the payment of the cost of consumables for the provision of high-tech medical care, which should be carried out at the expense of funds budget of the constituent entity of the Russian Federation. In other words, the expenditure of compulsory medical insurance funds, which are strictly targeted, was carried out in areas not provided for by the sources of funding.

For reference. In the Letter of FFOMS dated 06.06.2013 N 4509/21-i clarifications were given on certain areas of spending the CHI funds. In particular, in accordance with the recommendations of officials, the costs of purchasing furniture, including medical and kitchen furniture, are not included in the tariff for paying for medical care under the basic compulsory medical insurance program. An exception is equipment that, according to the certificate (declaration) of conformity by virtue of the Classification of fixed assets, belongs to class 14 3311320 "Equipment for offices and wards, equipment for laboratories and pharmacies" Section 14 0000000 "Machinery and equipment".

According to the Decree of the FAS ZSO, taking into account the provisions of Federal Law N 326-FZ on the misuse of compulsory medical insurance funds, the organization pays a fine in the amount of 10% of the amount of inappropriate use of compulsory medical insurance funds and a penalty in the amount of 1/300 of the refinancing rate of the Bank of Russia in effect on the day of the imposition of sanctions, for every day of delay.

In the Resolution of the Federal Antimonopoly Service of the UO dated 10.10.2013 N F09-10575 / 13 in case N A60-1177 / 2013, when considering a dispute over a similar violation, the arbitrators also sided with the TFOMS, indicating that the costs of medical organizations for the purchase of disinfectants should be carried out exclusively at the expense of funds of the budget of the constituent entity of the Russian Federation. The territorial program of state guarantees for the free provision of medical care to citizens of the Russian Federation residing in the territory of the constituent entity of the Russian Federation for the corresponding year does not provide for such expenses. By the definition of the Supreme Arbitration Court of the Russian Federation of January 23, 2014 No. VAS-18262/13, the institution was refused to revise this Resolution.

A similar violation was considered in the Resolution of the Federal Antimonopoly Service of the NKR dated 01.10.2012 N A22-1961 / 2011. The territorial program that was in force in the period under review on the territory of the constituent entity of the Russian Federation provided for lists of diseases, types of medical care and medical institutions included in the compulsory medical insurance system, as well as funded from the republican budget. As follows from the designated territorial compulsory medical insurance program, the costs of professional training and retraining of personnel should be carried out at the expense of the republican budget, medical and other services provided in the pathological and anatomical bureaus (offices) were provided at the expense of the republican and local budgets.

According to sect. III and IV of the named program, the inspected medical institution was included both in the list of institutions included in the CHI system and in the list of institutions financed from the republican budget.

FAS NKO established that medical services of a pathologist, in accordance with the specified territorial compulsory medical insurance program, are not subject to financing from the compulsory medical insurance funds. Since the payment of the salary to the pathologist was also financed from the republican budget, the court concluded that the expenses for the advanced training of the named doctor constituted the misuse of compulsory medical insurance funds, which are subject to refund.

Violation of the application of the budgetary classification of the Russian Federation in the implementation of expenses on CHI. In the Resolution of the FAS PO dated 03.25.2014 N A12-19994 / 2013, a dispute between the Ministry of Health of a constituent entity of the Russian Federation and FFOMS was considered.

In the course of the audit, the foundation found that in violation of paragraph 3 of Art. 50 of the Federal Law N 326-FZ under the state contract for the purchase of devices for medical laboratory research, the Ministry at the expense of the CHI acquired consumables under the health care modernization program. Recall that in accordance with paragraphs. 1 of this paragraph, the funds provided for in the FFOMS budget for the financial support of regional programs for the modernization of healthcare in the constituent entities of the Russian Federation are directed to the following purposes:

1) to strengthen the material and technical base of state and municipal healthcare institutions, including the construction, reconstruction of capital construction facilities and (or) their stages, ensuring the completion of the construction of previously started facilities, overhaul of state and municipal healthcare institutions, the purchase of medical equipment;

2) on the introduction of modern information systems in health care in order to create a unified state information system in the field of health care, the transition to compulsory medical insurance policies of a single sample, including the universal electronic card provided by the federal electronic application, the introduction of telemedicine systems, electronic document management systems and maintaining medical records of patients in electronic form;

3) to introduce standards of medical care, increase the availability of outpatient medical care, including that provided by specialist doctors.

As pointed out by the FFOMS representatives, the purchased consumables cannot be recognized as medical equipment, since they do not belong to code 3311000 "Medical and surgical equipment, orthopedic devices" OK 004-93, therefore, they are not included in the list established by paragraph 3 of Art. 50 of the Federal Law N 326-FZ.

The Ministry of Health of a constituent entity of the Russian Federation received funds from the CHI for the implementation of the healthcare modernization program, which is reflected in article 310 "Increase in the cost of fixed assets" of KOSGU.

Consumables purchased at the expense of the allocated funds (chemical reagents, laboratory glassware) are inventories, since they have a useful life of less than 12 months, and on the basis of clause 118 of Instruction N 157n<1> are subject to accounting on account 105 06 "Other material reserves".

Thus, the court confirmed the foundation's conclusion that the ministry committed a violation in the form of improper use of the CHI funds.

Purchase of consumables not used in medical practice. As already noted, one of the guarantees ensuring both the strictly targeted use of compulsory medical insurance funds and taking into account the rights and interests of a medical organization, the compulsory medical insurance fund and the insurer is the establishment of tariffs for paying for medical care under compulsory medical insurance in accordance with the Federal Law N 326-FZ tariff structure. The indicated tariff includes a list of expenses of medical organizations that they incur in connection with the provision of medical care under compulsory medical insurance programs (Article 30, Part 7, Article 35 of Federal Law N 326-FZ). Thus, as the arbitrators noted in the Resolution of the Federal Antimonopoly Service of the Moscow Region of April 30, 2014 N А41-38789 / 13, the acquisition of liquid technical oxygen by a health care institution at the expense of the compulsory medical insurance funds is their misuse. This conclusion is based on the fact that oxygen included in the State Register of Medicines and purchased from a supplier that has a license to manufacture it can be used for medical purposes. The acquisition of technical oxygen clearly contradicts the permissible goals of its use in medical activities, which means that it cannot be regarded as the intended use of compulsory medical insurance funds.

Payment of wages to pharmacy employees at the expense of compulsory medical insurance funds. The essence of the violation, which was brought before the court, was as follows. TFOMI conducted a documentary audit of the use of CHI funds aimed at paying for medical services provided by a medical institution within the framework of the territorial CHI program. In the course of the audit, the misuse of the compulsory medical insurance funds was revealed, expressed in the issuance of salaries with accruals to the employees of the hospital pharmacy at the expense of the compulsory medical insurance funds. Since these expenses do not correspond to the provisions of the territorial program of state guarantees of free provision of medical care to citizens of the Russian Federation residing in the constituent entity of the Russian Federation, the institution was ordered to restore the compulsory medical insurance funds spent not for their intended purpose.

FAS UO in the Resolution of 11.01.2012 N F09-8757 / 11 reasonably indicated that a pharmacy organization, including a structural unit of a health care institution, carries out pharmaceutical activities, that is, activities in the field of circulation of medicines, including wholesale, retail trade in medicinal means and their manufacture. In this case, a pharmacy organization is understood as an organization, a structural unit of a medical organization engaged in retail trade in medicinal products, their storage, manufacture and dispensing for medical use.

The arbitrators drew attention to the fact that the provision of citizens with medicines within the framework of the territorial program implies the purchase of medicines by medical organizations for their free provision when providing medical assistance to citizens, while the pharmacy of a medical institution dispenses medicines. The activities of pharmacies are not related to medical activities, that is, to activities directly aimed at providing medical services. In such circumstances, the court refused the medical institution to satisfy the stated requirements for invalidating the TFOMI prescription.

The illegality of attracting personal funds of citizens who are insured under the compulsory medical insurance, when providing them with medical care within the framework of the territorial program. According to paragraphs. "B" clause 1 h. 1 art. 16 of Federal Law N 326-FZ, insured persons have the right to free medical care by medical organizations in the event of an insured event in the territory of the constituent entity of the Russian Federation in which the compulsory health insurance policy was issued, in the amount established by the territorial compulsory health insurance program.

Territorial programs of state guarantees of free provision of medical care to citizens of the constituent entities of the Russian Federation approve a list of types of medical care that is provided free of charge. This list includes primary health care, which includes, in particular, measures for the prevention, diagnosis and treatment of diseases. Primary health care is provided on an outpatient basis and in a day hospital.

During the inspection in the republican hospital TFOMS, it was revealed that citizens purchased the drugs "Gadovist" and "Omnipak", belonging to the pharmacological group and pharmacological action of contrasting diagnostic drugs used exclusively for diagnostic purposes, for cash, which is a violation ...

As noted by the arbitrators in the Resolution of the FAS VCO dated 01.07.2014 N A58-5989 / 2013, the hospital is obliged to provide diagnostic drugs free of charge as part of the provision of services for the diagnosis of diseases as an integral part of primary health care provided on an outpatient basis. In this regard, the TFOMS rightfully issued an order to the hospital to reimburse the unjustifiably spent amounts to citizens who bought medicines for their own money.

In the Decree of March 25, 2014 N А78-4168 / 2013, the court of the same district considered the dispute between the hospital and the TFOMS concerning the collection of fees from patients for performing an operation in the provision of medical care provided under the state guarantees program. As noted by the arbitrators, from the totality of the provisions of Part 1 of Art. 11, paragraph 1, part 3 of Art. 80 of the Federal Law N 323-FZ<2> it follows that when providing medical care within the framework of territorial programs of state guarantees for the provision of medical care, they are not subject to payment from the personal funds of citizens:

- provision of medical services;

- prescription and use of medicinal products included in the list of vital and essential medicinal products, medical devices, blood components, medical nutrition, including specialized medical nutrition products, for medical reasons in accordance with the standards of medical care.

Thus, the issued order of the TFOMS meets the requirements of the legislation of the Russian Federation.

In conclusion, we note that for the use of funds received for the provision and payment of medical care under the compulsory medical insurance, medical institutions pay a fine in the amount of 10% of the amount of their inappropriate use, not for their intended purpose. In addition, it will be necessary to pay a penalty in the amount of 1/300 of the refinancing rate of the Bank of Russia, in effect on the day of the imposition of sanctions, of the amount of inappropriate use of these funds.

Funds used not for their intended purpose, the institution must be transferred to the budget of the TFOMI within 10 working days from the date of the presentation of the corresponding request by the TFOMI (clause 9 of article 39 of Federal Law N 326-FZ).

In case of non-fulfillment by the medical institution of the requirements of TFOMS for the return (reimbursement) of funds, including those used not for their intended purpose, and (or) payment of fines, penalties, TFOMS may send relevant information and verification materials to law enforcement and judicial authorities to bring the perpetrators to justice ...

The presence of this right also does not exclude the right to claim in court to bring a medical organization to justice in the form of a fine, provided for in Part 9 of Art. 39 of the Federal Law N 326-FZ (Resolution of the Federal Antimonopoly Service of the ZSO dated 04.14.2014 N A75-3259 / 2013).

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, terms, quality and conditions for the provision of medical care, conducts medical and economic control, medical and economic expertise, expertise of the quality of medical help, including repeated.

39. Repeated medical and economic examination or examination of the quality of medical care (hereinafter referred to as re-examination) is a medical and economic examination conducted by another expert-expert or another expert of the quality of medical care examination of the quality of medical care in order to verify the validity and reliability of conclusions on previously adopted conclusions made a specialist-expert or an expert on the quality of medical care, who initially conducted a medical and economic examination or an 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 by the same method, but by a different expert on the quality of medical care.

40. The objectives of the re-examination are:

a) verification of the validity and reliability of the conclusion of a specialist expert or an expert on the quality of medical care, who primarily conducted a medical and economic examination or an examination of the quality of medical care;

b) control of the activities of individual experts / experts on the quality of medical care.

41. Re-examination is carried out in the following cases:

a) the territorial compulsory health insurance fund conducts a documentary check of the compulsory health insurance organization by the medical insurance organization;

b) identification of violations in the organization of control by the medical insurance organization;

c) groundlessness and / or unreliability of the conclusion of the expert of the quality of medical care who carried out the examination of the quality of medical care;

d) receipt of a claim from a medical organization that has not been settled with an insurance medical organization (clause 73 of Section XI of this Procedure);

e) receipt of a complaint from the insured person or his representative about the quality of medical care.

(clause "d" was introduced by FFOMS Order of December 29, 2015 N 277)

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 a relevant request, an insurance medical organization and a medical organization must provide:

medical insurance organization - copies of acts of medical and economic control, medical and economic examination and examination of the quality of medical care necessary for the 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 that carried out by the health management body.

43. The number of cases subject to re-examination is determined by the number of reasons for their conduct in accordance with paragraphs 40 of this Procedure, and is:

a) from the number of primary medical and economic examinations not less than:

8% - in a round-the-clock hospital;

8% - in a day hospital;

0.8% - with outpatient care;

3% - ambulance outside the medical organization;

b) from the number of primary examinations of the quality of medical care at least:

5% - in a round-the-clock hospital;

3% - in a day hospital;

0.5% - for outpatient care;

1.5% - emergency medical aid outside the medical organization.

During a calendar year, all medical insurance organizations operating in the field of compulsory health insurance must be subject to re-examination in cases of medical care in all medical organizations.

(Clause 43 as amended by the FFOMS Order dated 22.02.2017 N 45)

44. The territorial fund of compulsory medical insurance sends the results of the re-examination drawn up by the act (Appendix 7 to this Procedure) to the insurance medical organization and the medical organization no later than 20 working days after the end of the inspection. An insurance medical organization and a medical organization are obliged to consider these acts within 20 working days from the date of their receipt.

45. An insurance medical organization and a medical organization, in the absence of agreement with the results of the re-examination, shall send a signed act with a protocol of disagreements to the territorial fund of compulsory medical insurance 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, considers the act with the protocol of disagreements with the involvement of interested parties.

46. \u200b\u200bIn accordance with part 14 of Article 38 of the Federal Law, the territorial compulsory medical insurance fund, in the event of violations of contractual obligations by an insurance medical organization, when reimbursing it for medical care costs, reduces payments by the amount of identified violations or unfulfilled contractual obligations.

The list of sanctions for violations of contractual obligations is established by an agreement on the financial support of compulsory health insurance, concluded between the territorial fund of compulsory health insurance and an insurance medical organization.

In accordance with this agreement, in the event of violations in the activities of an insurance medical organization, the territorial compulsory medical insurance fund uses the 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 and recognizes those applied by the medical insurance organization to the medical organization the measures are unreasonable.

(as amended by the FFOMS order of 21.07.2015 N 130)

(see text in previous edition)

47. The territorial fund of compulsory medical insurance, upon detecting violations in the organization and carrying out a medical and economic examination and / or examination of the quality of medical care, sends a claim to an insurance medical organization, which contains information about the control over the activities of an insurance medical organization:

a) the name of the commission of the territorial compulsory health insurance fund;

Registration N 23953

In accordance with the Federal Law of 29.11.2010 N 326-FZ "On compulsory medical insurance in the Russian Federation" (Collected Legislation of the Russian Federation, 2010, N 49, Art. 6422; 2011, N 25, Art. 3529; N 49, Art. . 7047, art. 7057) i order:

Approve:

Regulation on control over the activities of medical insurance organizations in the field of compulsory health insurance by territorial compulsory health insurance funds (Appendix 1);

Regulation on control over the use of compulsory health insurance funds by medical organizations (Appendix 2).

Chairman A. Yurin

Appendix 1

Regulations on the control over the activities of medical insurance organizations in the field of compulsory health insurance by territorial compulsory health insurance funds

I. General provisions

1. This Regulation was developed in accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Health Insurance in the Russian Federation" (Collected Legislation of the Russian Federation, 2010, N 49, Art. 6422; 2011, N 25, Art. 3529 , N 49, Art. 7047, 7057) (hereinafter - Federal Law N 326-FZ) for the purpose of regulatory and methodological support of the activities of territorial compulsory health insurance funds (hereinafter - territorial funds) to monitor the activities of medical insurance organizations in the field of compulsory medical insurance, including control over the use of compulsory health insurance funds by medical insurance organizations, by conducting inspections and audits (hereinafter referred to as inspections).

II. Organization of inspection

2. The territorial fund conducts inspections of medical insurance organizations (branches of medical insurance organizations) carrying out (carrying out) activities in the field of compulsory medical insurance on the basis of an agreement concluded between the territorial fund and an insurance medical organization (branch of an insurance medical organization) (hereinafter - medical insurance organizations ).

3. Inspections are carried out by employees of the control and audit divisions of the territorial fund and (or) other structural divisions of the territorial fund in order to prevent and identify violations of the norms established by Federal Law N 326-FZ, other federal laws and other regulatory legal acts of the Russian Federation adopted in accordance with them. Federation, laws and other regulatory legal acts of the constituent entities of the Russian Federation.

4. Inspections are carried out at the location of the medical insurance organization (or at the place of actual implementation of its activities), including:

a comprehensive audit, in which a set of issues is considered related to compliance with the legislation on compulsory health insurance and the use of compulsory health insurance funds for a certain period of activity of an insurance medical organization;

a thematic check, in which certain issues are considered related to compliance with the legislation on compulsory health insurance and (or) using the means of compulsory health insurance;

control check, in which the results of the work of an insurance medical organization are considered to eliminate violations and deficiencies previously identified during a comprehensive or thematic check.

The frequency of scheduled inspections is established taking into account the possibility of full coverage of the issues and periods of activity of medical insurance organizations in the field of compulsory health insurance, but not less than 1 (one) time per year. The frequency of scheduled comprehensive inspections is set no more than 1 (one) time per year.

The territorial fund may carry out unscheduled inspections. Unscheduled inspections are carried out by the decision of the director of the territorial fund on the basis of submissions from control bodies, appeals to the territorial fund of state authorities of the constituent entity of the Russian Federation, the Federal Compulsory Medical Insurance Fund (hereinafter referred to as the Federal Fund), appeals, complaints and applications of citizens in connection with the expiration of the term the fulfillment by an insurance medical organization of the requirements of the territorial fund to eliminate violations and shortcomings, and (or) return (reimburse) funds, and (or) pay fines (penalties), the Federal Fund checks compliance with the legislation on compulsory health insurance in the territory of the subject of the Russian Federation and the use of funds of compulsory health insurance by participants of compulsory health insurance, in the event of termination of the contract on financial support of compulsory health insurance, including in connection with the suspension or termination of actions a license, liquidation of an insurance medical organization, in connection with the appeal of an insurance medical organization to the territorial fund with an application for the provision of missing funds to pay for medical care within the framework of the territorial program of compulsory medical insurance and other necessary cases.

The order to conduct a scheduled inspection is communicated to the head of the medical insurance organization no later than 3 (three) business days before the start of the inspection. An unscheduled inspection can be carried out without complying with the condition of mandatory notification of the head of the medical insurance organization about the upcoming inspection.

The numerical and personal composition of the commission (working group) (from among the employees of the territorial fund) and the period of the inspection are established taking into account the topic of the inspection, the specifics of the activities of the insurance medical organization (including the number of insured persons by the medical insurance organization included in the regional segment of the unified register of insured persons , the number of points of issuance of compulsory health insurance policies, the number of medical organizations that have concluded an agreement with an insurance medical organization for the provision and payment of medical care for compulsory health insurance), the duration of the period being checked and the method of verification.

When checking the activities of an insurance medical organization on issues related to the processing of personal data, the commission (working group) must include employees of the territorial fund who have access to personal data.

The inspection period cannot exceed 30 (thirty) calendar days. If necessary, on a reasoned submission in the form of a memo of the head of the control and auditing unit of the territorial fund (the head of another subdivision of the territorial fund responsible for organizing a specific inspection) or the head of the commission (working group), the inspection period may be extended on the basis of the order of the territorial fund, but not more than 10 (ten) calendar days. The order of the territorial fund on the extension of the inspection period is communicated to the inspected medical insurance organization.

7. For the inspection, an inspection program is drawn up or a standard inspection program is used, which are approved by the director of the territorial fund.

the name of the medical insurance organization whose activities are subject to verification (when approving the standard verification program - the name of the medical insurance organization is not indicated);

the purpose of the check;

the topic of the check (for scheduled checks - the topic is indicated in accordance with the plan of checks; for unscheduled checks - the topic is indicated based on the specific reasons for its implementation);

a list of issues related to the activities of an insurance medical organization subject to verification.

When drawing up the inspection program, a list of issues related to the activities of medical insurance organizations in the field of compulsory health insurance, as reflected in paragraphs 15-20 of these Regulations, can be used.

8. Before the start of the inspection, the head and members of the commission (working group) must familiarize themselves with the agreements concluded between the territorial fund and the inspected medical insurance organization, reporting and statistical data available in the territorial fund, data on the number of insured persons by the medical insurance organization in the constituent entity of the Russian Federation and the dynamics of its change, with information from the territorial fund sent to the medical insurance organization, on the exclusion of insured persons from the register of this medical insurance organization for justified reasons, with acts of previous inspections carried out by the territorial fund, acts of inspections by control bodies, information on the elimination of identified violations and shortcomings and other materials related to the activities of the inspected medical insurance organization.

If necessary, the inspection program may include questions taking into account the materials of previous inspections conducted by the territorial fund and (or) control bodies, analysis of reports of an insurance medical organization, data on the number of insured persons by an insurance medical organization in a constituent entity of the Russian Federation and the dynamics of its change, as well as other documents related to the activities of the inspected medical insurance organization in the field of compulsory health insurance.

9. Verification of the activities of an insurance medical organization can be carried out in a continuous or selective way.

III. Powers of the commission (working group) during the inspection of an insurance medical organization

to request and receive from the officials of the medical insurance organization the documents, explanations, information and their certified copies necessary for the inspection;

to carry out inspections of branches of an insurance medical organization, points of issuing compulsory medical insurance policies and medical organizations that have received compulsory medical insurance funds from the inspected medical insurance organization;

get access to information systems of an insurance medical organization designed to fulfill the obligations of an insurance medical organization in the field of compulsory health insurance (including those located at the points of issuance of compulsory health insurance policies), in the mode of viewing and selecting the necessary information, as well as receive copies of documents (in including electronic) and copies of other records (in the presence of employees of an insurance medical organization).

13. On the day of the start of the inspection, the head, members of the commission (working group) present a copy of the order to the head of the medical insurance organization (the person replacing him) (in the case of an audit of the activities of the branch of the medical insurance organization - the head of the branch of the medical insurance organization (the person substituting him) territorial fund on the inspection, service certificates.

14. The head of an insurance medical organization (a person substituting him) (in case of an audit of the activities of a branch of an insurance medical organization - the head of a branch of an insurance medical organization (a person substituting for him) represents the head and members of the commission (working group) to the heads of structural divisions of an insurance medical organization and appoints a responsible person who coordinates the work of structural divisions of a medical insurance organization when conducting an inspection of an insurance medical organization.

The head of an insurance medical organization (a person substituting for him) (in the event of an audit of the activities of a branch of an insurance medical organization - the head of a branch of an insurance medical organization (a person substituting for him) is obliged to provide the head and (or) members of the commission (working group) with the opportunity to get acquainted with the documents, related to verification issues.

15. The main issues of the activities of medical insurance organizations in the field of compulsory health insurance are subject to verification:

organization and implementation of compulsory medical insurance (clause 16 of these Regulations);

organization and control of volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance (clause 17 of these Regulations);

protection of the rights and legitimate interests of insured persons, consideration of appeals and complaints of insured persons (clause 18 of these Regulations);

fulfillment of requirements for the placement of information by medical insurance organizations (clause 19 of these Regulations);

compliance by an insurance medical organization with the procedure for implementing the activities of the regional program for the modernization of health care of the constituent entity of the Russian Federation on the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures for carrying out in-depth medical examination of adolescents) (paragraph 20 of these Regulations).

16. Checking the organization and implementation of compulsory health insurance in medical insurance organizations includes checking:

16.1. The constituent documents of the medical insurance organization, amendments and additions to them.

16.2. Power of attorney issued to the head of a branch of an insurance medical organization, its validity period (in case of checking the activities of a branch of an insurance medical organization).

16.3. Licenses of an insurance medical organization for compulsory medical insurance, the date of its issuance by the federal executive body exercising control and supervision functions in the field of insurance activities (the original or a duly certified copy is considered).

16.4. Compliance by an insurance medical organization with the norms of Part 3 of Article 14 of Federal Law N 326-FZ (no other activities of an insurance medical organization, except for activities related to compulsory and voluntary medical insurance).

16.5. Compliance of documents of an insurance medical organization with the information contained in the register of medical insurance organizations operating in the field of compulsory medical insurance of a constituent entity of the Russian Federation.

16.6. Compliance with the procedure for issuing a policy of compulsory medical insurance to an insured person (including at points of issuing compulsory medical insurance policies) established by the Rules of compulsory medical insurance approved by order of the Ministry of Health and Social Development of the Russian Federation of February 28, 2011 N 158n (registered by the Ministry of Justice of the Russian Federation 03.03 .2011, registration N 19998) (as amended by order of the Ministry of Health and Social Development of the Russian Federation of 08/10/2011 N 897n) (registered by the Ministry of Justice of the Russian Federation on August 12, 2011, registration N 21609) (as amended by order of the Ministry of Health and Social Development of the Russian Federation of 09.09.2011 N 1036n) (registered by the Ministry of Justice of the Russian Federation on 14.10.2011, registration N 22053) (hereinafter referred to as the Rules of Compulsory Medical Insurance), including checks:

statements on the choice (replacement) of an insurance medical organization;

power of attorney from a representative of the insured person;

compliance by an insurance medical organization with the requirements established by Chapter II of the Rules of Compulsory Medical Insurance, when submitting an application for choosing (replacing) an insurance medical organization by an insured person;

observance of the procedure for issuing a policy of compulsory medical insurance (hereinafter - the policy) or a temporary certificate to the insured person, established by Chapter IV of the Rules of Compulsory Medical Insurance;

the timeliness of the issuance of a temporary certificate to the insured person or his representative, confirming the execution of the policy and certifying the right to free provision of medical care to the insured person by medical organizations in the event of an insured event;

observance of the deadlines for the transfer of information about the insured person who submitted an application for the selection (replacement) of an insurance medical organization to the territorial fund and the deadlines for checking whether the insured person has a valid policy in the regional segment of the unified register of insured persons;

compliance with the requirements of the procedure for maintaining personalized records in the field of compulsory medical insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation dated 25.01.2011 N 29n "On approval of the Procedure for maintaining personalized records in the field of compulsory medical insurance" (registered by the Ministry of Justice of the Russian Federation on 08.02.2011, registration N 19742), including the presence of an order defining employees of an insurance medical organization admitted to work with the regional segment of the unified register of insured persons, compliance with the terms of transfer of data on insured persons and information on changes in this data to the territorial fund, reliability of information entered by an insurance medical organization to the regional segment of the unified register of insured persons;

informing the insured about the timing of issuing and issuing policies in order to ensure the timely issuance of policies;

the timeliness of issuance of the policy to the insured person (within the period established by clause 50 of the Rules of Compulsory Health Insurance: not exceeding the validity period of the temporary certificate) and the reasons for non-compliance with the terms of issue;

compliance with the terms and procedure for informing citizens about the fact of insurance and the need to obtain a policy - for citizens, information about which was received by an insurance medical organization from a territorial fund in accordance with part 6 of article 16 of Federal Law N 326-FZ;

information on the number of insured persons by an insurance medical organization in the constituent entity of the Russian Federation, the dynamics of its change;

availability of reconciliation acts with the territorial fund of data on the number of insured persons on the first day of each month, the reliability of the specified data on the number of insured persons;

reliability of data on the number of insured persons used by the medical insurance organization when drawing up applications for receiving funds from the territorial fund;

collection and processing of data by an insurance medical organization of personalized accounting of information about insured persons and personalized accounting of information about medical care provided to insured persons, ensuring their safety and confidentiality, exchanging this information between participants of compulsory medical insurance in accordance with Federal Law N 326-FZ ...

16.7. Verification of keeping records of forms of temporary certificates and compulsory health insurance policies, as forms of strict accountability, including checking:

availability of analytical accounting for each type of strict reporting forms and places of their storage;

fulfillment of the requirements for ensuring the safety of temporary certificates and compulsory health insurance policies, as strict reporting forms, including at the points of issuance of compulsory health insurance policies;

the presence of an order from an insurance medical organization, agreed with the territorial fund, on the creation of a commission to write off and destroy policies and temporary certificates;

observance of the timing of the inventory, established by the accounting policy of the medical insurance organization (during the audit, an inventory or selective inventory of policies and temporary certificate forms, including at the points of issuance of compulsory medical insurance policies, can be carried out).

16.8. Verification of payment for medical care provided to insured persons, including verification of:

contracts for the provision and payment of medical care for compulsory health insurance;

compliance by an insurance medical organization with the norm of Part 1 of Article 39 of Federal Law N 326-FZ (conclusion of an agreement for the provision and payment of medical care for compulsory medical insurance with medical organizations included in the register of medical organizations operating in the field of compulsory medical insurance of a constituent entity of the Russian Federation (hereinafter - register of medical organizations);

compliance of the concluded contracts for the provision and payment of medical care under compulsory medical insurance to the form of a model contract for the provision and payment of medical care under compulsory medical insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation of 24.12.2010 N 1184n (registered by the Ministry of Justice of the Russian Federation on 04.02. 2011, registration N 19714) (hereinafter referred to as the Model Agreement for the provision and payment of medical care for compulsory health insurance);

the presence of refusals to conclude an agreement for the provision and payment of medical care for compulsory health insurance with a medical organization included in the register of medical organizations;

settlement accounts of an insurance medical organization (including checking the agreement with the bank for settlement and cash services) and accounting for compulsory medical insurance funds in the accounts;

compliance with the requirement for separate accounting of operations on voluntary and compulsory health insurance;

availability of balances of compulsory health insurance funds at the start and end date of the audited period, as well as on the date of the commencement of the audit;

the presence of the balances of the formed reserves not used at the end of 2011, and the implementation of their return to the territorial fund;

the timeliness of submission by the medical insurance organization to the territorial fund of applications for earmarked funds to advance payment for medical care and applications for earmarked funds to pay bills for medical care provided;

the correctness of drawing up applications for earmarked funds to advance payment for medical care and to receive earmarked funds to pay bills for medical care provided (taking into account advances to medical organizations that were not confirmed by the registers of accounts for the previous month) and the direction of earmarked funds to medical organizations, including in order to exclude the facts of overstating the amounts of funds in the application for receiving funds from the territorial fund and the facts of unreasonable receipt of funds for the specified application due to inaccurate data on the number of insured persons by this medical insurance organization;

the correctness of the formation of targeted funds for the payment of medical care at the expense of funds received from the territorial fund for the financial provision of compulsory medical insurance, funds received from medical organizations as a result of the application of sanctions against them for violations identified during the control of volumes, terms, quality and conditions of provision medical assistance in the field of compulsory medical insurance, funds received from legal entities or individuals that have caused harm to the health of insured persons (verification of the formation of targeted funds is carried out on the basis of checking the banking operations of an insurance medical organization);

the correctness of the formation of own funds in the field of compulsory health insurance from the sources provided for by Federal Law N 326-FZ, in accordance with the requirements established by the Model Agreement on the financial support of compulsory health insurance (hereinafter referred to as the Model Agreement on financial support);

availability of separate accounting of own funds and earmarked funds for payment of medical care;

use of earmarked funds received in the audited period and carry-over balances of earmarked funds to pay for medical care (based on the regulatory provisions of Part 6 of Article 39 of Federal Law No. 326-FZ and the terms of the Model Agreement on financial support and the Model Agreement on the provision and payment of medical care for compulsory medical insurance, payment for medical care provided to the insured person is carried out on the basis of the registers of bills and bills for medical care submitted by the medical organization within the scope of the provision of medical care established by the decision of the Commission for the development of a territorial program on tariffs for payment of medical care, taking into account the results of volume control , terms, quality and conditions for the provision of medical care for compulsory health insurance. Checking the use of targeted funds is carried out by checking the banking operations of an insurance medical organization and registers of accounts and invoices for payment of medical care (taking into account the results of control of volumes, terms, quality and conditions for the provision of medical care for compulsory medical insurance);

compliance of the payment for medical care by the medical insurance organization with the cost of the medical care provided in the registers of accounts and bills for medical care submitted by the medical organization (taking into account the results of monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance);

the existence of claims for reimbursement of expenses for the provision of medical care due to harm to the health of the insured person (recourse claims) (except for cases of harm caused by a serious accident at work) if the medical insurance organization has information;

fulfillment by an insurance medical organization of the terms of contracts for the provision and payment of medical care for compulsory medical insurance in terms of compliance with the terms of transfer of funds to a medical organization;

the validity of appeals of an insurance medical organization to the territorial fund for the provision of earmarked funds in excess of the established amount of funds for paying for medical care for this medical insurance organization from the standardized insurance stock of the territorial fund;

the reliability of the report of the medical insurance organization on the use of earmarked funds submitted to the territorial fund simultaneously with the application for the provision of earmarked funds in excess of the established amount of funds for paying for medical care for the given medical insurance organization from the standardized insurance stock of the territorial fund;

the timeliness of the direction by the medical insurance organization of the funds received from the normalized insurance stock of the territorial fund to pay for medical care provided to insured persons within the framework of the territorial compulsory medical insurance program;

the correspondence of the data contained in the acts of reconciliation of settlements between the territorial fund and medical insurance organizations (reconciliation of calculations is carried out monthly) with the accounting data of the insurance medical organization;

timeliness of payment to medical organizations for medical care provided to insured persons, taking into account the results of control of volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance;

the presence of a debt of an insurance medical organization to medical organizations and the identification of its causes, the presence and validity of claims of medical organizations to an insurance medical organization;

the existence of acts of reconciliation of settlements between an insurance medical organization and medical organizations (according to the Model Agreement for the provision and payment of medical care for compulsory medical insurance, the reconciliation of calculations by an insurance medical organization and a medical organization is carried out monthly on the 1st day of the month following the reporting month, as well as annually as of the end of the financial year, based on the results of which an act of acceptance for payment of the provided medical care is drawn up, confirming the amount of the final settlement between the parties);

the timeliness and completeness of the return of the balance of targeted funds to the territorial fund after the completion of settlements with medical organizations for the reporting month;

compliance with the terms of return (reimbursement) by an insurance medical organization of compulsory medical insurance funds, used not for their intended purpose, to the budget of the territorial fund and payment of penalties based on the results of inspections previously conducted by the territorial fund (if any);

observance of the deadlines for notifying insured persons, medical organizations and the territorial fund of the intention to terminate the contract at the initiative of the medical insurance organization (in case of early termination of the contract on financial support of compulsory medical insurance);

observance of the deadlines for the return of funds to the budget of the territorial fund upon termination of the contract on financial support of compulsory medical insurance;

the reliability and timeliness of submission to the territorial fund of reports on the activities of an insurance medical organization in the field of compulsory medical insurance and reports on the receipt and expenditure of compulsory medical insurance funds by medical insurance organizations.

16.9. Verification of the use of funds of the reserve of financial support for preventive measures of an insurance medical organization, formed in accordance with the agreement on financial support, including checking:

compliance with the conditions for transferring funds from the reserve of financial support for preventive measures to medical organizations

the timeliness and completeness of the return to the territorial fund of the balance of the financial provision for preventive measures unused by the medical insurance organization.

17. Verification of the organization and implementation of control by an insurance medical organization of the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance includes checking:

17.1. Compliance by an insurance medical organization with the rules and procedures for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care for compulsory medical insurance, established by order of the Federal Fund dated 01.12.2010 N 230 "On approval of the procedure for organizing and monitoring volumes, terms, quality and conditions for the provision of medical care for compulsory medical insurance "(registered by the Ministry of Justice of the Russian Federation on 01/28/2011, registration N 19614) (as amended by order of the Federal Fund of 08/16/2011 N 144) (registered by the Ministry of Justice of the Russian Federation on 09.12.2011, registration N 22523) (hereinafter - the order of the Federal Fund N 230). Medical and economic control, medical and economic examination, examination of the quality of medical care, including repeated ones, are carried out. During the check, the facts of payment for medical care according to bills and registers of accounts with violations in their registration and presentation for payment by medical organizations in accordance with section 5 of the List of grounds for refusing to pay for medical care (reducing payment for medical care), which is Appendix 8 to the Order of Organization and control of the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance (hereinafter referred to as the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care), approved by order of the Federal Fund No. 230, and for payment of medical care when collection of fees from insured persons (within the framework of voluntary medical insurance or in the form of provision of paid services) for the medical care provided under the territorial compulsory medical insurance program (clause 1.4. of the List of grounds for refusing to pay for medical care (reduction of fees for medical care), which is Appendix 8 to the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care).

17.2. Compliance of the composition of experts in the quality of medical care of an insurance medical organization with the requirements of the Procedure for organizing and monitoring the volume, timing, quality and conditions of medical care and the Procedure for maintaining the territorial register of quality experts of medical care by the territorial compulsory medical insurance fund and posting it on the official website of the territorial compulsory medical insurance fund on the Internet, approved by the order of the Federal Fund dated 13.12.2011 N 230 "On approval of the Procedure for maintaining the territorial register of experts on the quality of medical care by the territorial compulsory medical insurance fund and posting it on the official website of the territorial compulsory medical insurance fund on the Internet (registered The Ministry of Justice of the Russian Federation 02/01/2012, registration N 23086) (hereinafter - the Procedure for maintaining the register of experts), including checking the availability of documents required for the inclusion of specialist doctors in the territorial register of experts on the quality of medical care provided for by the Procedure for maintaining the register of experts.

17.3. Conducting expert work, including checking:

compliance with the terms of control of the volumes, terms, quality and conditions for the provision of medical care established by the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care;

implementation of the scope of medical and economic control, medical and economic examination and examination of the quality of medical care, established by the Procedure for organizing and monitoring the volume, timing, quality and conditions of medical care;

reliability and timeliness of submission of reports on the results of control of volumes, terms, quality and conditions for the provision of medical care.

When checking the expert work of an insurance medical organization, it is also reflected:

the presence of unjustified withdrawals from medical organizations of funds based on the results of monitoring the volumes, terms, quality and conditions for the provision of medical care in the implementation of compulsory medical insurance;

the presence of undetected defects in the provision of medical care;

non-application of penalties to medical organizations based on the results of monitoring the volumes, terms, quality and conditions for the provision of medical care if there are grounds for their application;

the presence of claims from medical organizations based on the results of control of the volumes, terms, quality and conditions of medical care provided by an insurance medical organization.

18. Verification of the activities of a medical insurance organization to protect the rights and legitimate interests of insured persons regarding the consideration of appeals and complaints of citizens (insured persons) includes verification of:

procedure for servicing persons with disabilities, including disabled persons;

work with citizens' appeals for compliance with the Federal Law of 02.05.2006 N 59-FZ "On the Procedure for Considering Appeals of Citizens of the Russian Federation" (Collected Legislation of the Russian Federation, 2006, N 19, Art. 2060; 2010, N 27, Art. 3410; N 31, Art.4196) and other normative legal acts regulating the work with citizens' appeals;

receiving, recording (registering) incoming appeals (complaints, applications) of insured persons, including about the choice of a doctor and a medical organization, about the volume and quality of medical care provided in medical organizations, etc .;

timeliness of consideration and validity of decisions made on applications. The verification reflects the facts of violation of the terms of consideration of applications of insured persons, failure to communicate to the applicant the results of consideration of applications (complaints, applications) or examination of the quality of medical care;

completeness of consideration of the appeal (application, complaint);

accounting of planned and unscheduled examinations of the quality of medical care, incl. repeated when medical organizations disagree;

the presence of refusals to conduct an examination of the quality of medical care upon the complaint of the insured person and their reasons;

registration of cases of pre-trial and judicial resolution of controversial issues and conflict situations with the participation of an insurance medical organization arising between medical organizations and patients;

availability of information on the consent of a citizen or his legal representative to resolve a conflict situation in a pre-trial procedure, offered by a medical organization or an insurance medical organization;

organization and conduct of activities by an insurance medical organization aimed at studying citizens' satisfaction with the quality of medical care provided;

availability in the medical insurance organization of the analysis of the results of sociological surveys (questionnaires) on the satisfaction of the insured persons with the availability and quality of medical care;

the availability of an analysis of the work carried out by an insurance medical organization with citizens' appeals and measures taken to prevent the occurrence of complaints;

reliability and timeliness of submission of reports on the organization of protection of the rights of insured persons in the field of compulsory health insurance.

19. Verification of compliance with the requirements for the placement of information by medical insurance organizations includes verification of:

availability of its own official website of the medical insurance organization on the Internet. Compliance with the requirements for the placement of information by medical insurance organizations, established by Chapter XIII of the Rules for Compulsory Health Insurance. Compliance of the information posted on the official website of the medical insurance organization on the Internet, legislative and other regulatory legal acts;

ensuring that insured persons are informed about the types, quality and conditions for the provision of medical care to them by medical organizations, violations identified in the provision of medical care to them, the right to choose a medical organization, the need to apply for a compulsory medical insurance policy, as well as the obligations of insured persons in accordance with the Federal Law N 326-Ф3; availability of information stands (posters) at the points of issuance of compulsory health insurance policies;

ensuring the provision of information to insured persons who have asked a question, including by e-mail or on the official website in the information and communication network "Internet" in the "question-answer" mode.

20. Checking the issue of compliance by an insurance medical organization with the procedure for implementing the activities of the regional program for the modernization of healthcare in the constituent entity of the Russian Federation (hereinafter referred to as the Modernization Program) for the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures for carrying out in-depth clinical examination adolescents), includes checking:

additional agreements to contracts for the provision and payment of medical care for compulsory medical insurance (these additional agreements must be concluded with medical organizations included in the list of medical organizations that are paid for medical care under the Modernization Program);

compliance with the procedure for the formation and submission to the territorial fund of applications for obtaining funds for the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by medical specialists, established by order of the Federal Fund dated 22.02.2011 N 40 "On approval of the procedure for the formation and application form to receive funds for the introduction of standards of medical care, increasing the availability of outpatient medical care, including that provided by medical specialists "(registered by the Ministry of Justice of the Russian Federation on 01.04.2011, registration N 20370);

payment for medical care provided under the Modernization Program at the expense of the budget of the Federal Fund (compliance with the payment of medical care under the Modernization Program of the established additional tariffs and payment terms). Verification of the use of funds for these purposes is carried out on the basis of bank documents of an insurance medical organization and registers of accounts and accounts for payment of medical care within the framework of the Modernization Program at the expense of the budget of the Federal Fund;

compliance of medical care payments made by an insurance medical organization within the framework of the Modernization Program at the expense of the budget of the Federal Fund for the cost of medical care provided by the medical organization in the registers of accounts and invoices for payment of medical care under the Modernization Program at the expense of the budget of the Federal Fund;

compliance by an insurance medical organization with the procedure for determining from the total amount of funds received from the territorial fund according to differentiated per capita standards, the amount of funds allocated to pay for medical care within the framework of the Modernization Program at the expense of the budget of the territorial fund, as well as funds from the budget of the constituent entity of the Russian Federation (if the specified funds provided as financial support for the territorial compulsory health insurance program and transferred to the budget of the territorial fund in the form of interbudgetary transfers);

payment for medical care provided under the Modernization Program at the expense of the budget of the territorial fund and the budget of the constituent entity of the Russian Federation (if these funds are provided), compliance by an insurance medical organization when paying for medical care provided under the Modernization Program at the expense of the budget of the territorial fund and the budget of the constituent entity of the Russian Federation, the procedure for implementing the Modernization Program and spending funds for the Modernization Program, approved on the territory of the constituent entity of the Russian Federation;

fulfillment by an insurance medical organization of the obligation to allocate in the total amount of funds allocated to medical organizations to pay for medical care under the territorial compulsory health insurance program, including the amount of funds allocated under the Modernization Program at the expense of the budget of the territorial fund, as well as funds from the budget of the subject The Russian Federation (if these funds are provided);

the insurance medical organization's control over the volumes, terms, quality and conditions for the provision of medical care within the framework of the Modernization Program; fulfillment by the medical insurance organization of the obligation to reflect in the acts of control of the volumes, terms, quality and conditions for the provision of medical care within the framework of the Modernization Program, funds that are not payable under the Modernization Program;

fulfillment by the medical insurance organization of the obligation to separately reflect in the accounting records the receipts and expenditures of funds within the framework of the Modernization Program by sources with analytical accounting on sub-accounts;

fulfillment by the medical insurance organization of the obligation to return to the territorial fund the funds of the Federal Fund budget that have not been spent for the purposes specified in the application for their receipt (in the event that the balance of these funds is formed as a result of the termination or suspension of the activities of the insurance medical organization);

availability in the medical insurance organization of reports of medical organizations on the use of funds for the purposes of implementing the regional program for the modernization of healthcare;

formation and reliability of reports of an insurance medical organization on the use of funds for the purposes of implementing the Modernization Program;

execution by the medical insurance organization of the decisions taken by the working group on the analysis of the implementation of the Modernization Program, created in the constituent entity of the Russian Federation.

V. Registration of the inspection report

21. Based on the results of the inspection, an inspection report is drawn up, including:

21.1. The heading part, which indicates the name of the inspection topic, the full name of the medical insurance organization (branch of the medical insurance organization) and the date of the act.

the period being checked;

surnames, initials of the head of the medical insurance organization (branch of the medical insurance organization), the deputy head of the medical insurance organization (branch of the medical insurance organization), the chief accountant and other officials of the medical insurance organization (branch of the medical insurance organization), who in the audited period had the right to the first ( second) signature. If there are changes in the audited period in the composition of the aforementioned persons, their list is provided with the simultaneous indication of the period during which these persons occupied the relevant positions in accordance with orders, orders for their appointment and dismissal from their position;

a list and details of all accounts of an insurance medical organization (branch of an insurance medical organization) (including accounts closed as of the date of the audit, but valid in the audited period) used by the audited medical insurance organization when carrying out activities in the field of compulsory medical insurance opened in credit institutions, indicating the cash balances as of the start and end date of the audited period, as well as on the date of the commencement of the audit;

other data necessary for a complete description of the insurance medical organization, including the inspection report briefly reflects information on previous inspections of the activities of the insurance medical organization by the control authorities, on the date and the period under review by the previous inspection conducted by the territorial fund, on the elimination (non-elimination) of deficiencies and violations identified by the previous check, if they were not eliminated, the reasons are indicated;

information on the method of conducting the check by the degree of coverage of primary documents (continuous, selective) with an indication of which documentation was checked in a continuous way, and which in a selective way;

information about the inspections of branches of an insurance medical organization, points of issuance of compulsory medical insurance policies, medical organizations that have received compulsory medical insurance funds from the inspected medical insurance organization;

a description of the verified issues of the activity of the medical insurance organization in accordance with the verification program (if necessary, based on the specific circumstances of the verification, the verification report may reflect information on the issues and periods of the activity of the medical insurance organization not included in the audited period and the verification program).

A description of the facts of violations and shortcomings identified during the audit (including the facts of misuse of compulsory medical insurance funds and the facts of violation of contractual obligations for which the application of penalties is envisaged) must contain mandatory information about specifically violated norms of legislative, other regulatory legal acts or their individual provisions indicating for what period the violations were committed, when and in what they were expressed, the amounts of documented inappropriate expenses and expenses incurred in violation of legislative and other regulatory legal acts.

In case of failure to submit or incomplete submission by the medical insurance organization of documents for the inspection, the inspection report contains a list of them.

21.3. The final part, which includes generalized information on the results of the audit, indicating the identified violations and shortcomings and the timing of their elimination or the time frame for submitting an action plan to eliminate the identified violations and shortcomings.

Upon revealing the facts of violation of contractual obligations established by the contract on financial support of compulsory medical insurance, including the facts of inappropriate use of compulsory medical insurance funds by an insurance medical organization, as well as facts of non-return (non-refund) and (or) untimely return (untimely compensation) of medical insurance the organization of compulsory medical insurance funds used for other purposes, the budget of the territorial fund, the final part of the inspection report includes generalized information on the directions of violations of contractual obligations and the amounts of misuse of compulsory medical insurance funds with a claim for return (compensation) by an insurance medical organization (branch) insurance medical organization) funds used not for their intended purpose, and payment of a fine for using not for their intended purpose by an insurance medical organization c funds, in accordance with parts 11, 12 of article 38 of Federal Law N 326-FZ and (or) payment of fines, penalties for violation of contractual obligations.

In case of establishing the facts of non-return to the budget of the territorial fund of earmarked funds that were not used by an insurance medical organization (branch of an insurance medical organization) for the intended purpose, remaining after fulfilling in full their obligations under contracts for the provision and payment of medical care for compulsory medical insurance, and ( or) in the event of termination of the contract on the financial support of compulsory medical insurance, including in connection with the suspension or termination of the license, liquidation of an insurance medical organization, the final part of the inspection report includes the requirement to return the specified funds to the budget of the territorial fund, as well as payment of penalties for untimely return of funds to the budget of the territorial fund upon termination of the contract on financial support of compulsory health insurance within ten working days from the date of termination of the contract.

21.4. Certification part, including surnames, initials, positions and signatures of the head and members of the commission (working group) who checked the activities of the insurance medical organization, surnames, initials, positions and signatures of officials of the verified medical insurance organization:

when checking the activities of medical insurance organizations (legal entities) - the verification act is signed by the head and members of the commission (working group), the head of the medical insurance organization (a person replacing him) and the chief accountant of the medical insurance organization;

when checking the activities of branches of medical insurance organizations - the inspection report is signed by the head and members of the commission (working group); the head of the branch of the medical insurance organization (a person substituting him) and the chief accountant of the branch of the medical insurance organization.

22. The inspection report is drawn up in two copies, which are equally valid. To the head of an insurance medical organization (a person replacing him) (in the case of an audit of the activities of a branch of an insurance medical organization - to the head of a branch of an insurance medical organization (a person replacing him), an inspection report in two copies for review and signing is submitted no later than 1 (one) the day before the end of the inspection period, determined by the order of the territorial fund on the inspection.

One copy of the signed inspection report is handed over to the head of the medical insurance organization (the person who replaces him) (in case of checking the activities of the branch of the medical insurance organization - to the head of the branch of the medical insurance organization (the person who replaces him), the second copy is submitted to the territorial fund.

In a copy of the inspection report, which is submitted to the territorial fund, a record is made on the receipt of one copy of the inspection report by the head of the medical insurance organization (a person substituting for him). Such a record must contain, among other things, the date of receipt of the verification certificate, the signature of the person who received the verification certificate, and a decryption of this signature.

The date of receipt of the act by the head of the medical insurance organization (the person replacing him) is considered the date of the end of the inspection.

In case of refusal of the head of an insurance medical organization (a person substituting him) to sign and (or) receive an inspection report by the head of the commission (working group), at the end of the inspection report, a record is made of the refusal to sign the inspection report or refusal to sign in receiving the inspection report.

In case of refusal of the head of an insurance medical organization (a person replacing him) (the head of a branch of an insurance medical organization (a person substituting him) to sign and receive an inspection report, the date of the end of the inspection and the date of receipt of the inspection report is considered the sixth working day from the date of sending the inspection report to the insurance a medical organization (branch of an insurance medical organization) by registered mail with acknowledgment of receipt.

The document confirming the fact of sending the inspection report to the medical insurance organization is attached to the inspection materials.

In case of disagreement with the act of verification (or its individual provisions), the head of the insurance medical organization signing it (the person substituting him) (the head of the branch of the insurance medical organization (the person replacing him) makes an entry that the act is signed with objections that are attached to the act of verification or are sent to the territorial fund no later than 5 (five) working days from the date of receipt of the inspection report. Written objections of the insurance medical organization to the inspection report are attached to the inspection materials.

In case of refusal of officials of an insurance medical organization (branch of an insurance medical organization) to sign an inspection report or to receive an inspection report and (or) failure to submit written objections to an inspection report, the end date of the inspection is considered the sixth working day from the date of dispatch of a medical insurance organization (to a branch of a medical insurance organization) the act of verification by registered mail with acknowledgment of receipt.

23. The following shall be attached to the act of inspection when violations and shortcomings are revealed:

tables of necessary calculations;

acts of inspections of branches of an insurance medical organization, points of issuing compulsory medical insurance policies, medical organizations that have received compulsory medical insurance funds from the inspected medical insurance organization;

other necessary materials.

All applications drawn up during the audit must be signed by the head or a member of the commission (working group) and the head (a person substituting him) of the inspected medical insurance organization (in the case of an audit of the activities of a branch of an insurance medical organization - by the head of a branch of an insurance medical organization (a person, his substitute) (with visas page by page).

Copies of documents confirming the violations identified during the inspection, including violations in the use of compulsory medical insurance funds, are certified by the signature of the head of the medical insurance organization or the chief accountant of the medical insurance organization and the seal of the medical insurance organization. If necessary, it is allowed to draw up a register of primary documents confirming violations, including violations in the use of compulsory medical insurance funds, which is signed by the head or a member of the commission (working group) and the head of the medical insurance organization (a person replacing him) (in the case of an audit of the branch of an insurance medical organization - by the head of a branch of an insurance medical organization (a person substituting for him) or a chief accountant of an insurance medical organization (a branch of an insurance medical organization) (with visas per page) and certified by the seal of an insurance medical organization (a branch of an insurance medical organization).

24. Not later than 10 (ten) business days after the end of the inspection, the head of the commission (working group) submits to the director (deputy director) of the territorial fund an official note on the results of the inspection of the activities of the medical insurance organization in the field of compulsory medical insurance.

25. If there are written objections to the inspection report, no later than 5 (five) working days from the date of their receipt, the territorial fund sends the head of the medical insurance organization (the head of the branch of the medical insurance organization) a written message on the results of consideration of objections to the inspection report, prepared by the structural unit of the territorial fund, responsible for organizing the conduct of a specific inspection, signed by the director (deputy director) of the territorial fund, indicating the grounds on which the objections are recognized as unfounded, or on the recognition of justified objections (partially justified objections) of an insurance medical organization.

If the objections are not recognized as justified or if the objections of the medical insurance organization are partially justified, the written message includes information that the terms of elimination of the violation and (or) the terms of the return (reimbursement) of funds, including those used not for their intended purpose, and (or) payment fines, penalties are calculated from the date of submission of the corresponding claim by the territorial fund.

A written message on the results of consideration of objections to the inspection report is handed to the head of an insurance medical organization (branch of an insurance medical organization) or a person authorized by him, on receipt, or sent to an insurance medical organization (branch of an insurance medical organization) by registered mail with a receipt acknowledgment.

A copy of the written message of the territorial fund on the results of considering the objections of the insurance medical organization (branch of the insurance medical organization) to the inspection report and a document confirming the fact of sending the said written message to the insurance medical organization (branch of the medical insurance organization) are attached to the inspection materials.

In case of disagreement with the result of consideration by the territorial fund of written objections to the inspection report, the insurance medical organization (branch of the insurance medical organization) has the right to appeal this decision in a pre-trial and (or) court procedure.

26. The return (reimbursement) of funds, including those used not for their intended purpose, and (or) payment of fines, penalties is carried out by an insurance medical organization (a branch of an insurance medical organization) on the basis of an inspection report in the manner prescribed by Federal Law N 326-FZ.

27. The territorial fund ensures control over the implementation of the results of the audit, including:

control over the return (reimbursement) of funds, including those used not for their intended purpose;

accrual of penalties and sending a written message to the medical insurance organization about the need to pay penalties (with the attachment of calculating the amount of penalties).

28. In accordance with Part 14 of Article 38 of Federal Law N 326-FZ, in the event of a violation of contractual obligations, the territorial fund, when reimbursing an insurance medical organization for the costs of paying for medical care, has the right to reduce payments by the amount of violations identified.

29. In case of revealing in the activities of an insurance medical organization (branch of an insurance medical organization) facts of violation of the legislation on compulsory medical insurance, requiring immediate measures to eliminate them, in case of non-fulfillment by an insurance medical organization (branch of an insurance medical organization) of the requirements of the territorial fund on the return (compensation ) funds, including those used not for their intended purpose, and (or) on the payment of fines, penalties, as well as in case of failure to eliminate the identified violations within the established time frame, the territorial fund has the right to send relevant information and inspection materials to law enforcement and judicial authorities to attract the perpetrators to responsibility.

Vii. Final provisions

30. Plans of inspections, programs of scheduled and unscheduled inspections (standard inspection programs), inspection materials, consisting of original copies of inspection reports and duly executed annexes to them, which are referenced in inspection reports, as well as documents provided for in Chapter VI of this Regulation, are completed, accounted for and stored in the manner prescribed by the legislation on archiving in the Russian Federation and the rules of office work in the territorial fund.

Appendix 2

Regulation on control over the use of compulsory health insurance funds by medical organizations

I. General provisions

1. This Regulation was developed in accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Health Insurance in the Russian Federation" (Collected Legislation of the Russian Federation, 2010, N 49, Art. 6422; 2011, N 25, Art. 3529 ; N 49, Art. 7047, Art. 7057) (hereinafter - Federal Law N 326-FZ) for the purpose of regulatory and methodological support of the activities of territorial compulsory medical insurance funds (hereinafter - territorial funds) to monitor the use of compulsory medical insurance funds by medical organizations by conducting inspections and audits (hereinafter - inspections).

II. Organization of inspection

2. The territorial fund conducts inspections of medical organizations in the field of compulsory health insurance (hereinafter referred to as 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:

organizations of any organizational and legal form provided for by the legislation of the Russian Federation;

individual entrepreneurs engaged in private medical practice.

3. Inspections are carried out by employees of the control and audit divisions of the territorial fund and (or) other structural subdivisions of the territorial fund in order to prevent and detect violations of the norms established by Federal Law N 326-F3, other federal laws and other regulatory legal acts of the Russian Federation adopted in accordance with them. Federation, laws and other regulatory legal acts of the constituent entities of the Russian Federation.

4. Checks are carried out at the location of the medical organization (or at the place of actual implementation of its activities), including:

a comprehensive audit, in which a set of issues related to the use of compulsory health insurance funds for a certain period of a medical organization's activity is considered;

a thematic check, in which certain issues related to the use of compulsory health insurance funds are considered;

control check, in which the elimination of violations and shortcomings by a medical organization in the use of compulsory medical insurance funds, previously identified during a comprehensive or thematic check, is considered.

5. The inspections are carried out in accordance with the plan approved by the director of the territorial fund (scheduled inspections).

The frequency of scheduled inspections is set taking into account the possibility of full coverage of issues and periods of activity of medical organizations in the field of compulsory health insurance, but not less than 1 (one) every two years. The frequency of scheduled comprehensive inspections is set no more than 1 (one) time per year.

The territorial fund may carry out unscheduled inspections. Unscheduled inspections of the use of compulsory medical insurance funds are carried out by decision of the director of the territorial fund on the basis of submissions from the control authorities, appeals to the territorial fund of state authorities of the constituent entity of the Russian Federation, the Federal Compulsory Medical Insurance Fund (hereinafter - the Federal Fund), appeals, complaints and applications of citizens, in connection with the expiration of the term for the medical organization to fulfill the requirements of the territorial fund to eliminate violations and deficiencies, and (or) return (reimburse) funds, and (or) pay fines (penalties), the Federal Fund checks compliance with the legislation on compulsory health insurance in the territory of the subject Of the Russian Federation and the use of compulsory medical insurance funds by participants of compulsory medical insurance, in the event of termination of the contract for the provision and payment of medical care under compulsory medical insurance registration, including in connection with the suspension or termination of the license, liquidation of a medical organization and other necessary cases.

6. The basis for the audit is the order of the territorial fund, which determines the subject of the audit, the audited period, the head and composition of the commission (working group), the timing of the audit.

For scheduled checks, the topic of the check is indicated in accordance with the plan of checks, for unscheduled checks, the topic of the check is indicated based on the specific reasons for its conduct.

The order to conduct a scheduled inspection is communicated to the head of the medical organization no later than 3 (three) working days before the start of the inspection. An unscheduled inspection can be carried out without complying with the condition of mandatory notification of the head of the medical organization about the upcoming inspection.

The numerical and personal composition of the commission (working group) (from among the employees of the territorial fund) and the period for conducting the inspection are established taking into account the topic of the inspection, the characteristics of the activities of the medical organization, the duration of the period being inspected and the method of inspection.

Depending on the topic of the audit, specialists from other control bodies may be included in the composition of the commission (working group) at the suggestions of the control bodies.

When checking the use of compulsory medical insurance funds by a medical organization related to the processing of personal data, the commission (working group) should include employees of the territorial fund who have access to personal data.

The inspection period cannot exceed 30 (thirty) calendar days. If necessary, on a reasoned submission in the form of a memo of the head of the control and auditing unit of the territorial fund (the head of another subdivision of the territorial fund responsible for organizing a specific inspection) or the head of the commission (working group), the inspection period may be extended on the basis of the order of the territorial fund, but not more than 10 (ten) calendar days. The order of the territorial fund on the extension of the inspection period is brought to the attention of the inspected medical organization.

7. To carry out the inspection, an inspection program is drawn up or a standard inspection program (hereinafter - the inspection program) is used, which are approved by the director of the territorial fund.

The verification program should contain the following information:

the name of the medical organization that is subject to verification in terms of the use of compulsory medical insurance funds (when approving the standard verification program, the name of the medical organization is not indicated);

the purpose of the check;

the topic of the check (for scheduled checks - the topic is indicated in accordance with the plan of checks; for unscheduled checks - the topic is indicated based on the specific reasons for its conduct);

a list of questions to be checked.

When drawing up the verification program, the list of issues reflected in clauses 15 - 22 of these Regulations can be used.

8. Before the start of the inspection, the head and members of the commission (working group) must familiarize themselves with the contracts concluded by the inspected medical organization with the territorial fund and (or) with medical insurance organizations operating in the field of compulsory health insurance, reporting and statistical data available in the territorial the fund, with acts of previous inspections carried out by the territorial fund, acts of inspections by supervisory authorities, information on the elimination of identified violations and shortcomings and other materials related to the use of compulsory medical insurance funds by the inspected medical organization.

If necessary, the inspection program may include questions taking into account the materials of previous inspections conducted by the territorial fund and (or) control bodies, analysis of reports of a medical organization, as well as other documents related to the use of compulsory medical insurance funds by the inspected medical organization.

9. Verification of the use of compulsory health insurance funds can be carried out in a continuous or selective way.

The continuous method consists in conducting a control action in relation to the entire set of financial, accounting, reporting and other documents related to one issue of the verification program.

The selective method consists in conducting a control action in relation to a part of financial, accounting, reporting and other documents related to one issue of the verification program. The size of the sample and its composition are determined by the head of the commission (working group) in such a way as to ensure the possibility of assessing the issue under study of the verification program.

The decision to use a continuous or selective method of conducting control actions on each issue of the verification program is made by the director (deputy director) of the territorial fund or the head of the structural unit of the territorial fund responsible for organizing the audit, and (or) the head of the commission (working group) based on the content of the question verification programs, the volume of financial, accounting, reporting and other documents related to this issue, the state of accounting, the timing of the audit.

III. Powers of the commission (working group) during the inspection of a medical organization

10. The leader and members of the commission (working group) have the right:

to request and receive from the officials of the medical organization the documents, explanations, information and their certified copies necessary for the inspection;

get access to information systems of a medical organization, designed to fulfill the obligations of a medical organization in the field of compulsory health insurance, in the mode of viewing and selecting the necessary information, as well as receive copies of documents (including electronic ones) and copies of other records (in the presence of employees of a medical organization) ...

11. The leader and members of the commission (working group) must:

be guided by legislative and other regulatory legal acts;

to objectively reflect in the documents the facts of violations and shortcomings revealed by the inspection.

12. The head of the commission (working group) organizes the work of the commission (working group).

When performing their official duties during the inspection, the members of the commission (working group) are subordinate to the head of the commission (working group).

IV. Checking procedure

13. On the day of the start of the inspection, the head, members of the commission (working group) present to the head of the medical organization (a person replacing him) a copy of the order of the territorial fund on the inspection, service certificates.

14. The head of the medical organization (a person substituting him) introduces the head and members of the commission (working group) to the heads of the structural units of the medical organization and appoints a responsible person who coordinates the work of the structural units of the medical organization during the inspection of the medical organization.

The head of a medical organization (a person replacing him) is obliged to provide the head and (or) members of the commission (working group) with the opportunity to familiarize themselves with the documents related to the issues of verification.

15. The directions of the use of funds received by medical organizations for financial support are subject to verification:

territorial compulsory health insurance program (clause 17 of these Regulations);

measures of the regional program for the modernization of healthcare in the constituent entity of the Russian Federation to introduce standards for the provision of medical care, increase the availability of outpatient medical care, including that provided by specialist doctors (including measures for conducting in-depth medical examination of adolescents) (paragraph 18 of these Regulations);

a priority national project in the field of healthcare, including conducting additional medical examination of working citizens, medical examination of orphans and children in difficult life situations staying in inpatient institutions, provision of additional medical care by district therapists, general practitioners (family doctors), nurses of district general practitioners of district doctors, pediatricians of district doctors and nurses of general practitioners (family doctors) (paragraphs 19-21 of this Regulation);

fulfillment of expenditure obligations of the constituent entities of the Russian Federation arising from the exercise by the state authorities of the constituent entities of the Russian Federation of the delegated powers of the Russian Federation as a result of the adoption of federal laws and (or) regulatory legal acts of the President of the Russian Federation, and (or) regulatory legal acts of the Government of the Russian Federation in the field of health protection citizens, and (or) arising from the adoption of laws and (or) regulatory legal acts of the constituent entities of the Russian Federation.

16. Checking the use of compulsory health insurance funds by a medical organization includes checking compliance with the requirement to maintain separate accounting for operations with compulsory health insurance funds.

17. Verification of the use of funds received by medical organizations for financial support of the territorial compulsory health insurance program includes verification of:

17.1. The justification for the receipt of funds by a medical organization to pay for medical care under compulsory health insurance, including checking:

the presence of a license of a medical organization for the right to carry out certain types of medical activities, the terms of its validity and the types of medical care and services specified in the license and accreditation certificates, and the types of medical care actually provided according to statistical documentation and consolidated accounting documents compiled on the basis of invoices, presented by a medical organization for payment for medical care provided;

the correctness of the preparation of applications for advance payments of medical care (in the amount of up to seventy percent of the average monthly amount of funds allocated to pay for medical care in accordance with the contract for the provision and payment of medical care for compulsory health insurance) and the timeliness of sending these applications (up to the 10th day of the current month);

the correctness and timeliness of the submission by the medical organization to the medical insurance organizations of the register of accounts and invoices for payment of medical care provided to the insured persons (within five working days of the month following the reporting month);

the correspondence of the amount of funds received to pay for medical care to the cost of medical care provided by the medical organization in registers of accounts and invoices for medical care (taking into account the results of monitoring the volumes, terms, quality and conditions of providing medical care under compulsory medical insurance). When checking, the facts of funds received for payment of medical care are reflected in bills and registers of accounts with violations in their registration and presentation for payment by a medical organization in accordance with section 5 of the List of grounds for refusing to pay for medical care (reducing payment for medical care), which is Appendix 8 to the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance (hereinafter - the Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care), approved by order of the Federal Fund of 01.12.2010 N 230 "On approval of the procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care for compulsory medical insurance" (registered by the Ministry of Justice of the Russian Federation on 01/28/2011, registration N 19614) (as amended by the order of the Federal Fund of 08/16/201 1 N 144) (registered by the Ministry of Justice of the Russian Federation on 09.12.2011, registration N 22523), and to pay for medical care when collecting fees from insured persons (within the framework of voluntary medical insurance or in the form of providing paid services) for medical care provided by the territorial the compulsory medical insurance program (clause 1.4 of the List of grounds for refusing to pay for medical care (reducing the payment for medical care), which is Appendix 8 to the Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care);

the presence of acts of reconciliation of settlements between a medical organization and medical insurance organizations (in accordance with the form of the Standard Agreement on compulsory medical insurance for the provision and payment of medical care, approved by order of the Ministry of Health and Social Development of the Russian Federation of December 24, 2010 N 1184n (registered by the Ministry of Justice of the Russian Federation 04.02. 2011, registration N 19714), reconciliation of calculations by an insurance medical organization and a medical organization is carried out monthly on the 1st day of the month following the reporting month, as well as annually as of the end of the financial year, based on the results of which an act of acceptance for payment of provided medical care is drawn up confirming the amount of the final settlement between the parties);

the presence, duration and size of accounts receivable and payable for payment of medical care, the reasons for the debt;

the existence and validity of claims of a medical organization against medical insurance organizations in terms of payment for medical care under compulsory medical insurance;

the presence of claims and (or) claims of insurance medical organizations against a medical organization in order to compensate for harm caused to the insured person and sanctions applied to a medical organization.

17.2. Compliance with the obligation of a medical organization to use compulsory medical insurance funds received for medical care provided in accordance with the territorial compulsory medical insurance program, including:

1) by type of medical care;

2) by the structure of the tariff for payment of medical care, including:

implementation of expenses for labor remuneration and accruals for payments for labor remuneration: correct calculation and payment of wages in accordance with the established rates, official salaries and actually worked hours, the validity of payments of various allowances and additional payments for combining professions and positions, etc. (all documents confirming the validity of payments made are checked: staffing table, tariff lists, documents confirming the qualifications of specialists, work schedules of structural divisions and employees, orders on personnel, labor agreements, collective agreement, wage regulations, etc.) , verification of primary accounting documents on the expenditure of compulsory medical insurance funds for payments (wages, bonuses, additional payments, incentives, material assistance), payment of taxes and insurance premiums established by the legislation of the Russian Federation. The audit reflects the cases of spending compulsory health insurance funds for payments (wages, bonuses, additional payments, incentives, material assistance) to persons not participating in the implementation of the territorial compulsory health insurance program;

implementation of expenses for the purchase of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, other inventories, to pay for the cost of laboratory and instrumental studies conducted in other institutions (in the absence of a laboratory and diagnostic equipment in a medical organization) , catering (in the absence of organized meals in a medical organization) (when checking, the amounts of expenses incurred are compared (including for the purchase of medicines, consumables, food, soft inventory, medical instruments, reagents and chemicals, other material supplies) with approved cost estimate).

Verification of the use of funds for these purposes is carried out by checking the primary documents confirming the legality of banking operations, including contracts for the supply of medicines, consumables, food products, soft inventory, medical instruments, reagents and chemicals, and other material supplies.

Checked:

reasonableness of prices when purchasing goods (works, services) at the expense of compulsory medical insurance funds;

observance of delivery and payment terms, compliance of the amounts specified in the contracts with the actual expenses incurred;

timeliness, completeness and correctness of posting of medicines and consumables, food products, soft inventory, medical instruments, reagents and chemicals, other material supplies;

safety, accounting and disposal of medicines, consumables, food products, soft inventory, medical instruments, reagents and chemicals, other material supplies;

the presence of separate accounting for medicines purchased at the expense of compulsory medical insurance funds and at the expense of funds received by a medical organization from other sources.

The analysis of purchased medicines is carried out (the availability of expired medicines is reflected).

Studied:

materials of an inventory of property and financial liabilities carried out by a medical organization (during the inspection, a selective inventory of fixed assets, inventories purchased at the expense of compulsory medical insurance can be carried out);

availability, duration and size of accounts receivable and payable with suppliers of goods and services at the expense of compulsory medical insurance funds, timeliness of collection of accounts receivable and repayment of accounts payable, mutual reconciliation in settlements with suppliers, correct accounting of these calculations, timeliness of collection of amounts of identified shortages and embezzlement of funds of compulsory medical insurance, material assets acquired at the expense of compulsory medical insurance funds, as well as losses from damage to these valuables attributed to the perpetrators.

If there are other areas of spending in the composition of the accepted tariffs for payment of medical care, verification of the use of compulsory medical insurance funds for the specified purposes is carried out taking into account the relevant documents regulating the procedure for conducting such expenses, the amount of funds provided for these expenses as part of the accepted tariffs for payment of medical care and the approved cost estimate, the terms of the concluded contracts.

When checking the use of compulsory health insurance funds:

the correctness of the reflection in the accounting registers of transactions on compulsory medical insurance funds, the correctness of the reflection of income and expenses in accordance with the current budget classification, compliance with the procedure for conducting cash transactions and accounting for cash (in terms of compulsory medical insurance funds), timeliness of posting cash of compulsory medical insurance received from the bank and other sources, as well as their intended use, the availability of supporting documents and the reliability of the data contained in them, which are the basis for writing off cash expenses, the legality of expenses incurred in terms of compulsory medical insurance, ensuring the safety of funds.

17.3. Availability and reliability of personalized accounting data of information about medical care provided to insured persons, transferred by a medical organization to a territorial fund and medical insurance organizations, which are necessary, among other things, to control the use of compulsory medical insurance funds.

17.4. The use by a medical organization of funds received from the reserve of financial support for preventive measures of an insurance medical organization, including checking the availability of reporting documents on funds received by a medical organization from the reserve of financial support for preventive measures.

17.5. The reliability and timeliness of the submission of reports by a medical organization on the use of compulsory medical insurance funds in accordance with the established forms.

18. Verification of the use of funds received for financial support of the activities of the regional program for the modernization of healthcare of the constituent entity of the Russian Federation (hereinafter - the Modernization Program) for the implementation of standards of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures for carrying out in-depth clinical examination adolescents), includes checking:

additional agreements to contracts for the provision and payment of medical care for compulsory health insurance on the interaction of the parties in the implementation of the Modernization Program;

provision by a medical organization to an insurance medical organization of a separate account and a register of accounts (or a separate account within the register of accounts for payment of medical care under the territorial program of compulsory medical insurance) for payment of medical care under the Modernization Program at the expense of the budget of the Federal Fund;

implementation of measures carried out at the expense of funds received for the implementation of standards, increasing the availability of outpatient medical care, and compliance with the conditions for the use of funds received to increase the availability of outpatient medical care from the budget of the Federal Fund, in accordance with the Decree of the Government of the Russian Federation of 15.02.2011 N 85 "On the approval of the Rules for financial support in 2011-2012 of regional programs for the modernization of healthcare of the constituent entities of the Russian Federation at the expense of funds provided from the budget of the Federal Mandatory Medical Insurance Fund" (as amended by Resolution of the Government of the Russian Federation dated 06.04.2012 N 286) (Collected Legislation of the Russian Federation , 2011, N 8, Art. 1126);

compliance with the conditions for the use of funds received for the implementation of standards from the budget of the Federal Fund, in accordance with the tariff agreement and the procedure for implementing the Modernization Program and spending funds for the Modernization Program, approved in the territory of the constituent entity of the Russian Federation;

implementation of measures and compliance with the conditions for the use of funds received under the Modernization Program from the budget of the territorial fund and the budget of the constituent entity of the Russian Federation (if these funds are provided), in accordance with the tariff agreement and the procedure for implementing the Modernization Program and spending funds for the Modernization Program approved in the territory of the constituent entity Russian Federation.

When checking the use of funds received for the financial support of the Modernization Program, the following are checked:

1) documents confirming the validity of spending funds, including:

licenses for the provision of medical services as part of the activities of the Modernization Program for the implementation of standards for the provision of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures for carrying out in-depth clinical examination of adolescents);

valid certificates of medical workers providing outpatient medical care, medical services within the framework of measures for the provision of medical care in accordance with the approved standards, taking part in the in-depth clinical examination of adolescents;

local documents defining the procedure and conditions for remuneration of medical workers as part of the implementation of measures of the Modernization Program for the implementation of standards for the provision of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures for carrying out in-depth medical examination of adolescents);

additional agreements to labor contracts concluded between the medical organization and its employees regarding the implementation of the Modernization Program;

2) the validity of the calculation of wages, the correctness of its calculations and the timing of payment, the payment of taxes and insurance premiums established by the legislation of the Russian Federation;

3) compliance with the procedures provided for by the Federal Law of July 21, 2005 N 94-FZ "On placing orders for the supply of goods, performance of work, provision of services for state and municipal needs" (Collected Legislation of the Russian Federation, 2005, N 30, Art. 3105; 2006, N 1, Art. 18; N 31, Art. 3441; 2007, N 17, Art. 1929; N 31, Art. 4015; N 46, Art. 5553; 2008, N 30, Art. 3616; N 49 , art.5723; 2009, N 1, art. 16; N 1, Art. 31; N 18, Art. 2148; N 19, Art. 2283; N 27, Art. 3267; N 29, Art. 3584; N 29, Art.3592; N 29, Art. 3601; N 48, Art. 5711; N 48, Art. 5723; N 51, Art. 6153; N 52, Art. 6441; 2010, N 19, Art. 2286; N 19, Art.2291; N 31, Art 4209; N 45, Art 5755; 2011, N 15, Art 2029; N 17, Art 2320; N 27, Art 3880; N 29, Art 4291 ; N 48, Art.6727; N 50, Art.7360; N 51, Art.7447; N 48, Art.6728; N 50, Art.7359), when determining suppliers of medicines and consumables, soft inventory, products food and other material supplies as part of the implementation of the Modernization Program for subsoil of standards for the provision of medical care, increasing the availability of outpatient medical care, including that provided by specialist doctors (including measures for carrying out in-depth medical examination of adolescents), the conclusion and execution of state (municipal) contracts, compliance with the delivery and payment terms;

4) the timeliness and reliability of these reports of a medical organization on the use of funds for the purposes of implementing the regional program for the modernization of health care (according to the forms approved by order of the Federal Fund dated 16.12.2010 N 240 "On approval of the Procedure and form for reporting on the use of funds for implementation purposes) regional programs for the modernization of health care of the constituent entities of the Russian Federation in the period 2011 - 2012 "(registered by the Ministry of Justice of the Russian Federation on December 31, 2010, registration N 19503), and by order of the Ministry of Health and Social Development of the Russian Federation of December 30, 2010 N 1240n" On the approval of the procedure and form reporting on the implementation of activities of regional programs for the modernization of healthcare in the constituent entities of the Russian Federation and programs for the modernization of federal state institutions providing medical care "(registered by the Ministry of Justice of the Russian Federation 0 1.02.2011, registration No. 19655);

5) the amount of allocated financing and cash expenses, if there are unused or unallocated funds - indicate the reasons for the deviations;

6) a separate reflection in the accounting records of the receipt and expenditure of funds under the Modernization Program for each source of financial support with analytical accounting on sub-accounts.

19. Verification of the use of funds received by a medical organization from the budget of the territorial fund for additional medical examination of working citizens.

When checking the use of funds received for financial support of additional medical examination of working citizens, the following are checked:

licenses for all types of medical activities required for additional medical examination of working citizens;

a list of employees participating in the additional medical examination of working citizens;

contracts concluded by the inspected medical organization with a medical organization licensed for types of medical activities that are absent in the inspected medical organization. Compliance with the term of the contract with the date of actual performance of work;

an estimate of income and expenditure on the funds received from the budget of the territorial fund for additional medical examination of working citizens, the execution of the estimate of income and expenditure;

2) targeted use of the funds received to conduct additional medical examination of working citizens in the established areas of spending;

3) making payments of wages at the expense of funds received for additional medical examination of working citizens, in accordance with the time sheets;

4) the accuracy of filling out the reporting form on the use of funds received for additional medical examination of working citizens;

5) a separate reflection in the accounting records of the receipt and expenditure of funds for additional medical examination of working citizens;

6) the number of working citizens who have undergone additional medical examination according to the lists of the medical organization and according to the registers of accounts for payment of the additional medical examination of working citizens.

During the inspection, a random check of the Registration Cards for additional medical examination of a working citizen can be carried out (registration form N 131 / u-DD-10, approved by order of the Ministry of Health and Social Development of the Russian Federation dated 04.02.2010 N 55n "On the procedure for additional medical examination of working citizens" (registered by the Ministry of Justice of the Russian Federation on 03/04/2010, registration N 16550) (as amended by order of the Ministry of Health and Social Development of the Russian Federation of 03.03.2011 N 163n) (registered by the Ministry of Justice of the Russian Federation on 03/28/2011, registration N 20308) (as amended by order Of the Ministry of Health and Social Development of the Russian Federation of 31.01.2012 N 70n) (registered by the Ministry of Justice of the Russian Federation on 22.02.2012, registration N 23309) (hereinafter - order N 55n) and the corresponding Medical records of an outpatient patient (registration form N 025 / u-04 , approved by order of Mi Ministry of Health and Social Development of the Russian Federation of November 22, 2004 N 255 "On the Procedure for the provision of primary health care to citizens entitled to receive a set of social services" (registered by the Ministry of Justice of the Russian Federation on December 14, 2004, registration N 6188), which determines justification for the use of funds, taking into account:

completeness of the additional medical examination (completed case) and the correctness of medical documentation by specialist doctors, compliance with the examination algorithm by specialist doctors;

the conformity of the conclusions of the medical specialists performing the examinations in the Card of the additional medical examination of a working citizen and the Medical card of the outpatient;

compliance of the specialties of doctors performing examinations with the specialties approved by order N 55n.

20. Verification of the use of funds received by a medical organization for financial support of medical examination of orphans and children in difficult life situations staying in inpatient institutions.

When checking the use of funds received for financial support of medical examination of orphans and children in a difficult life situation staying in inpatient institutions, the following are checked:

1) documents confirming the validity of spending funds for the specified purposes, including:

licenses for the types of medical activities necessary for the medical examination of orphans and children in difficult life situations staying in inpatient institutions;

a list of employees participating in the medical examination of orphans and children in difficult life situations staying in inpatient institutions;

contracts concluded by the inspected medical organization with a medical organization licensed for types of medical activities that are absent in the inspected medical organization, compliance of the contract validity period with the period of actual work performance;

an estimate of income and expenditure on the funds received from the budget of the territorial fund for conducting medical examination of orphans and children in difficult life situations staying in inpatient institutions, execution of the estimate of income and expenditure;

2) a separate reflection in the accounting records of the receipt and expenditure of funds for the medical examination of orphans and children in difficult life situations staying in inpatient institutions;

3) targeted use of the funds received for the medical examination of orphans and children in a difficult life situation staying in inpatient institutions, in accordance with the established directions of spending;

4) the reliability of the data in the reporting form on the use of funds received for medical examination of orphans and children in difficult life situations staying in inpatient institutions;

5) making payments of wages at the expense of funds received for the medical examination of orphans and children in difficult life situations staying in inpatient institutions, in accordance with the time sheets;

6) the number of children who underwent medical examination, according to the lists of the medical organization and according to the registers of accounts for payment of the medical examination carried out for orphans and children in difficult life situations staying in inpatient institutions.

During the inspection, a random check of the Dispensary Cards of orphans and children in difficult life situations staying in inpatient institutions can be carried out (registration form N 030-D / s / 09-10, approved by order of the Ministry of Health and Social Development of the Russian Federation dated 03.03 .2011 N 162n "On conducting medical examination of orphans and children in difficult life situations staying in inpatient institutions" (registered by the Ministry of Justice of the Russian Federation on 08.04.2011, registration N 20446) (hereinafter - order N 162n) and the corresponding medical records of the child , which determines the validity of the use of funds, taking into account:

completeness of the volume of the medical examination (completed case) and the correctness of the medical documentation by specialist doctors, compliance with the examination algorithm by specialist doctors;

compliance of the conclusions of medical specialists performing examinations in the Card of clinical examination of orphans and children in a difficult life situation staying in inpatient institutions with the child's medical record;

compliance of the specialties of doctors performing examinations with the specialties approved by order N 162n.

21. Checking the use of funds received by a medical organization from the budget of the territorial fund for the provision of additional medical care provided by district therapists, district pediatricians, general practitioners (family doctors), district nurses, district general practitioners, pediatricians of district , nurses of general practitioners (family doctors) (hereinafter - additional medical care):

When checking the use of funds received by a medical organization from the budget of the territorial fund for the provision of additional medical care, the following are checked:

a medical organization has licenses to provide appropriate medical care;

the presence of an open separate account for accounting of funds allocated to pay for additional medical care;

availability of a budget request and annex to it;

documents confirming the validity of the inclusion of employees of a medical organization in the budget application, information in the annex to the application, documents confirming the registration of labor relations between the employee and the medical organization (the number of attached population, order on the number of sites created, order of employment, work book, staffing table and etc.);

the presence of completed additional agreements to labor contracts (from the 1st working day of the month) between a medical organization and primary health care workers for the provision of additional medical care;

making payments in accordance with the application (staffing, timesheet, payroll, calculations for accruals for payments in accordance with the law);

reflection of transactions for settlements for additional medical care in accounting;

reliability of the data in the reporting form on the use of funds received for additional medical care.

22. Verification of the implementation of measures to eliminate violations and shortcomings identified by previous inspections, including compliance with the terms of return (reimbursement) by the medical organization of funds used not for their intended purpose to the budget of the territorial fund and (or) payment of penalties based on the results of inspections, earlier conducted by the territorial fund (if any).

V. Registration of the inspection report

23. Based on the results of the inspection, an inspection report is drawn up, including:

23.1. The heading part, which indicates the name of the inspection topic, the full name of the medical organization and the date of drawing up the act.

number and date of the order of the territorial fund to conduct an inspection;

surnames, initials and positions of the leader and members of the commission (working group) who carried out the inspection;

the start and end date of the inspection (the start date of the inspection, which is reflected in the content of the inspection report, is the start date of the commission (working group), and the end date is the date of signing the inspection report by the head and members of the commission (working group) who conducted the inspection, according to the order to conduct an inspection);

the name of the subject of the audit, indicating the nature of the audit (planned / unscheduled, complex);

the period being checked;

surnames, initials of the head of a medical organization, deputy head of a medical organization, chief accountant and other officials of a medical organization who had the right of the first (second) signature during the audited period. If there are changes in the audited period in the composition of the aforementioned persons, their list is provided with the simultaneous indication of the period during which these persons occupied the relevant positions in accordance with orders, orders for their appointment and dismissal from their position;

a list and details of all accounts of a medical organization (including accounts closed on the date of the audit, but valid in the audited period) used by the audited medical organization, indicating the balance of funds as of the start and end date of the audited period, as well as the date of the start of the audit;

information about the license (number, date of issue and expiration date);

other data necessary for a complete description of the medical organization, including the inspection report briefly reflects information on previous inspections of the use of compulsory medical insurance funds by the medical organization by the control authorities, on the date and the period being checked during the previous inspection by the territorial fund, on the elimination (non-elimination) of deficiencies and violations revealed by the previous check, if they are not eliminated, the reasons are indicated;

information on the method of conducting the check according to the degree of coverage of primary documents (continuous, selective) with an indication of which documentation was checked in a continuous way, and which in a selective way;

a description of the verified issues of the use of compulsory medical insurance funds in accordance with the verification program (if necessary, based on the specific circumstances of the verification, the verification report may contain information on the issues and periods of the medical organization's activities that are not included in the audited period and verification program).

The results of the inspection are set out in the inspection report on the basis of verified data and facts, confirmed by documents, the results of inspections and actual control procedures, and other actions related to the inspection.

A description of the facts of violations and shortcomings identified during the audit (including the facts of misuse of compulsory medical insurance funds) should contain mandatory information about specifically violated norms of legislative, other regulatory legal acts or their individual provisions, indicating for what period violations were committed, when and in what they were expressed, the amounts of documented inappropriate expenses and expenses incurred in violation of legislative and other regulatory legal acts.

In the inspection act, it is not allowed to include various kinds of conclusions, assumptions and facts that are not confirmed by primary and reporting documents.

In case of failure to submit or incomplete submission by the medical organization of documents for the inspection, a list of them is provided in the inspection report.

The scope of the inspection report is not limited by the number of pages.

23.3. The final part, which includes generalized information on the results of the audit, indicating the identified violations and shortcomings and the timing of their elimination or the time frame for submitting an action plan to eliminate the identified violations and shortcomings.

If there are facts of inappropriate use of compulsory health insurance funds identified during the audit, the final part of the act includes generalized information on the directions and amounts of inappropriate use of compulsory health insurance funds, with a requirement for the medical organization to return funds used not for their intended purpose and to pay a fine for the non-intended use by a medical organization of funds transferred to it under an agreement for the provision and payment of medical care for compulsory medical insurance, in accordance with part 9 of Article 39 of Federal Law N 326-FZ.

23.4. Certification part, including surnames, initials, positions and signatures of the head and members of the commission (working group) who checked the use of compulsory medical insurance funds, surnames, initials, positions and signatures of officials of the verified medical organization.

24. The inspection report is drawn up in two copies, which are equally valid. The head of a medical organization (a person replacing him) is provided with an inspection report in two copies for review and signing no later than 1 (one) day before the end of the inspection period determined by the order of the territorial fund on the inspection.

One copy of the signed act of verification is handed over to the head of the medical organization (person replacing him), the second copy is submitted to the territorial fund.

In a copy of the inspection report, which is submitted to the territorial fund, a record is made on the receipt of one copy of the inspection report by the head of the medical organization (his substitute). Such a record must contain, among other things, the date of receipt of the verification certificate, the signature of the person who received the verification certificate, and a decryption of this signature.

The date of receipt of the act by the head of the medical organization (the person replacing him) is considered the date of the end of the check.

If the head of the medical organization (person replacing him) refuses to sign and (or) receive the inspection report by the head of the commission (working group), at the end of the inspection report, a record is made about the refusal to sign the inspection report or the refusal to sign in receipt of the inspection report.

If the head of the medical organization (person replacing him) refuses to sign and receive the inspection report, the date of the end of the inspection and the date of receipt of the inspection report is considered the sixth working day from the date the inspection report is sent to the medical organization by registered mail with a receipt acknowledgment.

A document confirming the fact of sending the inspection report to the medical organization is attached to the inspection materials.

In case of disagreement with the verification act (or some of its provisions), the head of the medical organization signing it (the person replacing him) makes an entry that the act is signed with objections that are attached to the verification act or sent to the territorial fund no later than 5 (five) working days from the day of receipt of the inspection certificate. Written objections of the medical organization to the inspection report are attached to the inspection materials.

If the officials of the medical organization refuse to sign the inspection report or receive the inspection report and (or) failure to submit written objections to the inspection report, the end date of the inspection is considered the sixth working day from the date the medical organization sends the inspection report by registered mail with a receipt acknowledgment.

25. The following shall be attached to the act of inspection when violations and shortcomings are revealed:

tables of necessary calculations;

copies of documents confirming the facts of violations and shortcomings;

materials that are important for confirming the facts of violations and shortcomings reflected in the act;

other necessary materials.

All applications drawn up during the audit must be signed by the head or a member of the commission (working group) and the head (person substituting for him) of the audited medical organization (with visas per page).

Copies of documents confirming the violations identified during the inspection, including violations in the use of compulsory medical insurance funds, are certified by the signature of the head of the medical organization or the chief accountant of the medical organization and the seal of the medical organization. If necessary, it is allowed to draw up a register of primary documents confirming violations, including violations in the use of compulsory medical insurance funds, which is signed by the head or a member of the commission (working group) and the head of a medical organization (a person replacing him) or the chief accountant of a medical organization (with visas page by page) and certified by the seal of the medical organization.

If there are attachments, the text of the inspection report must contain obligatory references to them, and before the certification part of the inspection report, a list of attachments is provided with an indication of the number of sheets, copies, and a record is made that the attachments are an integral part of the inspection report.

Vi. Implementation of test results

26. Not later than 10 (ten) business days after the end of the inspection, the head of the commission (working group) submits to the director (deputy director) of the territorial fund a memo on the results of the inspection of the use of compulsory medical insurance funds by a medical organization.

27. The return (reimbursement) of funds, including those used not for their intended purpose, and (or) payment of fines, penalties is carried out by a medical organization on the basis of the received act in the manner prescribed by Federal Law N 326-FZ.

28. If there are written objections to the inspection report, no later than 5 (five) working days from the date of their receipt, the territorial fund sends a written message to the head of the medical organization on the results of consideration of objections to the inspection report, prepared by the structural unit of the territorial fund responsible for organizing a specific checks signed by the director (deputy director) of the territorial fund, indicating the grounds on which the objections are recognized as unfounded, or on the recognition of reasonable objections (partially justified objections) of the medical organization.

If the objections are not recognized as justified or if the objections of the medical organization are partially justified, the written message includes information that the timeframe for the elimination of the violation and (or) the timeframe for the return (reimbursement) of funds, including those not used for their intended purpose, and (or) payment of fines , penalties are calculated from the day the territorial fund submits the corresponding claim.

A written message on the results of consideration of objections to the inspection report is handed to the head of the medical organization or to a person authorized by him, against receipt, or sent to the medical organization by registered mail with a receipt acknowledgment.

A copy of the written message of the territorial fund on the results of consideration of the objections of the medical organization to the inspection report and a document confirming the fact of sending the specified written message to the medical organization are attached to the inspection materials.

In case of disagreement with the result of consideration by the territorial fund of objections to the inspection report, the medical organization has the right to appeal this decision in a pre-trial and (or) court order.

29. The territorial fund ensures control over the implementation of the results of the audit, including:

control over the submission and implementation of the action plan to eliminate the identified violations and shortcomings (if the territorial fund establishes a deadline for eliminating violations and shortcomings, control over the elimination of the identified violations and shortcomings within a specified time);

control over the return (reimbursement) of funds used not for their intended purpose;

control over the payment of fines, penalties;

accrual of penalties and sending a written message to the medical organization about the need to pay penalties (with the attachment of calculating the amount of penalties).

30. In case of revealing the facts of violation of the legislation on compulsory health insurance, requiring immediate measures to eliminate them, in case of non-fulfillment by the medical organization of the requirements of the territorial fund for the return (reimbursement) of funds, including those used not for their intended purpose, and (or) on payment fines, penalties, as well as in case of failure to eliminate the identified violations within the established time frame, the territorial fund has the right to send the relevant information and inspection materials to law enforcement and judicial authorities to bring the perpetrators to justice.

Vii. Final provisions

31. Inspection plans, programs of scheduled and unscheduled inspections (standard inspection programs), inspection materials, consisting of original copies of inspection reports and duly executed annexes to them, which are referenced in inspection reports, as well as documents provided for in Chapter VI of this Regulation, are completed, accounted for and stored in the manner prescribed by the legislation on archiving in the Russian Federation and the rules of office work in the territorial fund.

Life and health are constantly exposed to various dangers. Availability of medical insurance is an opportunity to timely receive the necessary qualified assistance.

In the case of paid treatment, the insurance allows you to fully or partially compensate material costs.

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If medical services are free, then the insurance policy will finance an additional set of medical procedures, and provide high-quality rehabilitation.

Features of the activity of medical insurance structures

Modern insurance structures provide two types of medical services:

• compulsory (state) insurance policy;
• voluntary agreement.

Compulsory health insurance () - the obligation of the state in the framework of existing social programs. The activities of the MHI are aimed at equalizing the opportunities for access to health care facilities for all citizens of the country.

Voluntary health insurance (VHI) is determined solely by the desire of citizens or employers and allows them to determine the list of necessary medical and other services in addition to those guaranteed by the state CHI fund. Voluntary medical insurance is concluded, both collective and personal.

Comparative table of CHI and VHI

The rights of individuals and the rules for their participation in the structure of health insurance are regulated by law. Stateless persons of the Russian Federation have the same rights when applying for health insurance as citizens of the country.

Insured events must be clearly stated in the contract, the rules and conditions for the provision of the policy. The indemnity is paid on condition that the situation corresponds to the insured event specified in the contract.

Insurance organizations rights

CMO has a wide range of powers and rights in terms of VHI registration. This type of insurance is currently regulated exclusively by general insurance laws.

Thus, they have the following rights:

• Choose any medical organizationwho will provide quality services to their clients;
• Conclude contracts with any medical and other specialized organizations to provide medical, rehabilitation and health procedures;
• Determine the amount of contributions;
• To independently agree on prices for the list of servicesthat provide medical facilities;
• Control the number of services, meeting deadlines, quality of treatment, representing and defending the interests of clients;
• To bring legal claims to medical institutions, their employees, if they are guilty of causing physical, moral or material damage to the client;
• Return a share of the sum insuredif this opportunity is provided for by the agreement (it is worth noting that such actions lead to the loss of tax benefits).

Obligations of health insurance organizations

The main responsibility of the MCO - conscientiously fulfill all clauses of the concluded contracts and ensure the quality fulfillment of their obligations by medical institutions.

The insurance company must ensure its solvency (financial reliability) by the presence of a paid authorized capital and required material reserves. They are also obliged to strictly comply with all regulatory relationships between existing assets and material liabilities.

Insurance employees are required to provide comprehensive support to clients if they encounter problems in obtaining medical care. For instance:

• difficulties arose when making an appointment with a specialized specialist, or during an examination;
• there are comments about the examination and treatment process, the quality of services;
• unreasonable demand for payment for examination, medical care, medicines and materials.

In insurance structures dealing with medical policies, there are special groups for highly professional protection of the rights of clients.

Qualified specialists refuse social, legal, economic support, participate in medical and economic examinations and examinations to determine the quality of services, contribute to judicial and judicial compensation for payment of treatment, compensation for harm that was caused to health by the actions of doctors.

A responsibility

All insurance companies are legally liable to the insurance supervisory authority in terms of:

• the validity of insurance rates;
• financial security;
• strict observance of all norms of the legislation of the Russian Federation.

Conflicts between clients and policyholders are settled in court.

Types of health insurance organizations

The main participants in the public health insurance system include:

• policyholders (organizations providing insurance services);
• insured citizens (clients);
• medical insurance organizations (CMO);
• various medical structures.

The first two groups have the same composition, legal obligations and level of responsibility as other representatives of the insurance business. According to the law "On compulsory health insurance in the Russian Federation", special requirements are imposed on the last two subjects.

CMOs are engaged in only one type of insurance and are not entitled to other types of activities. HMOs are not an integral part of the health care system; medical institutions cannot be founders of HMOs or participate in management.

Insurance organizations that have the right (license) to work under the voluntary health insurance program can only specialize in life and health insurance or provide other types of services. Those. the subject of voluntary medical insurance can be any organization specializing in the provision of insurance services and licensed for medical insurance.

Voluntary health insurance is carried out in the legal framework of the Law "On Insurance". It should be borne in mind that individual items of insurance documents from different insurers can significantly wear. Therefore, if you want to issue a VHI policy, you should be responsible when choosing an insurance company.

Clients are offered a wide range of various insurance programs. You can choose what is most relevant to a particular person. For example, insurance in case of disability (temporary / permanent), payment for rehabilitation actions, necessary sports and recreational activities, etc.

Policyholder selection criteria

The main criteria to be considered when choosing an insurance company:

• simplicity and execution of a package of documents;
• the reputation of the insurance organization;
• quality of service;
• timeliness of compensation payments;
• the level of insurance premiums;
• insurance policy level;
• coverage of diseases (list of insured events).

There is one more important criterion when preparing a package of documents for VHI - medical assistance.

Assistance ("assistance" - help) Is a complex of organizational services that facilitates the receipt by the company's clients of support (assistance) specified by the contract.

Assistance is an intermediary between the insurer and medical institutions. Insurance companies working with health insurance use two types of assistance:

• internal, which is part of the structure of this company;
• external (an independent company with which policyholders enter into service contracts).

Insurance companies that work with voluntary medical insurance, as a rule, interact with medical institutions (assistance companies). This approach provides conditions for the provision of professional medical care if the insured event occurred outside the territory of insurance registration, i.e. in any region of the country and even beyond its borders.

Medical insurance is important for the development of the healthcare system, allows you to provide diverse treatment procedures, creates conditions for the highest quality treatment of citizens.