The provision of medical care under the CHI policy guarantees the possibility of checking the composition and quality certain types services and procedures. Recently, such an opportunity has become available in electronic form by using the service "Personal account of the insured person", posted on the public services portal, as well as on various territorial portals. How to check the provided medical services? What to do if you managed to find services that were not provided? We will try to answer these and other questions in this article.
How to check the types of medical care provided under the CHI policy?
The transition to a system of individual informing citizens about the services provided and their cost made it possible to establish quality control of the medical care services provided. The electronic service "Personal account of the insured person" is available to citizens of the Russian Federation who have verification on the official portal of public services, and allows you to get information about the composition and cost of the types of assistance provided under compulsory medical insurance. For residents of certain regions, territorial electronic resources for more detailed information. The main purpose of such services - informing insured citizens receiving assistance under the CHI policy - is implemented in the following areas:
- By checking personal information about citizens: personal data, information about the number of the issued medical policy, contact information, name of the clinic;
- By entering information about existing and past diseases, injuries, and other medical indicators (blood type, possible allergic reactions, etc.);
- By obtaining data on all types of medical care provided to a citizen since January 2015, as well as the cost of their services when reimbursed from the compulsory medical insurance fund.
Information on the types of medical services provided is provided in the form of an extract, which is generated at the request of resource users. This extract is used with information purposes, as well as to control the composition and volume of medical care provided to the population. Besides, electronic service provides additional opportunities for planning events and activities related to the provision of medical services. Maintaining such a calendar-plan allows you to receive information about the upcoming procedure in the form of a reminder received by e-mail. In addition, such services can help.
Control of the list of services provided under the CHI policy
Verification of specific types of services provided under the CHI program may establish the presence of procedures or activities that the citizen did not actually receive. This fact may indicate either a technical error in the formation of database information, or a deliberate distortion of information in order to obtain reimbursement from the MHIF.
If this discrepancy is revealed, a citizen has the right to apply for clarification to the local institution of the Territorial Compulsory Medical Insurance Fund, or to insurance company that issued the CHI policy. An extract with a list of services recorded in the database, as well as evidence of non-receipt of the declared types of assistance, must be attached to the appeal.
If there are grounds, the Territorial Fund has the right to conduct unscheduled inspections of both the insurance company and the medical institution. When a technical error is identified, the database information will be updated. If, as a result of the audit, a violation is revealed in the procedure for providing medical care to citizens and receiving federal budget funds, then the perpetrators legal entities will be held accountable.
The holder of a compulsory medical insurance policy (CHI) can count on passing all the necessary examinations within the framework of the current insurance program. According to Law No. 323-FZ of November 21, 2011 “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, each insured person has the right to receive medical care in a guaranteed amount free of charge in accordance with the terms of the insurance contract. Are all MHI analyzes free of charge and what is included in this list?
Who pays for free tests
Medical care under the CHI policy is free only for its owner. As for hospitals and polyclinics providing outpatient and inpatient treatment to insured persons, each of these medical institutions is obliged to pay the following costs:
- maintenance of special equipment and troubleshooting;
- wages for medical workers;
- purchase of necessary reagents, tools and preparations.
All of the above insurance costs are covered by the Federal Compulsory Medical Insurance Fund (FOMS).
Rules for obtaining free analyzes
The receipt of a particular medical service under the CHI policy must be justified. When it becomes necessary to conduct any surveys, you need to proceed as follows:
- visit the clinic along with the compulsory medical insurance policy;
- contact a specialist of the required profile;
- get a referral for free tests.
The patient cannot independently decide which studies need to be done - this is determined by the doctor. All activities that are assigned by a specialist are done free of charge in the same clinic. If the clinic does not have the opportunity to conduct some research, the patient is sent to another medical institution.
On a note! When undergoing a course of treatment in a hospital under the CHI program, the patient has the right to receive all medical services free of charge.
How to get tested in another region
The volume of medical services under the compulsory insurance contract has some territorial restrictions. Outside their region, the insured person receives medical assistance under the terms of the basic program, which operates throughout the country. Within the boundaries of his region, he is served under a program approved by the Territorial Compulsory Medical Insurance Fund (TFOMS), which covers a wider range of services.
Rules for obtaining medical assistance under compulsory medical insurance in another region:
- during departure, the policy should be with you - it is better to take a picture of it and save the photo on your phone so that you can present it to health workers at least in this form;
- when they refuse to conduct a particular study on a free basis, explaining that this is not provided for by the basic program, you need to look into Art. 35 of the Federal Law No. 326-FZ of November 29, 2010 “On Compulsory Medical Insurance in the Russian Federation” (hereinafter - Federal Law No. 326). If the basic program does not provide for this type of examination, then the refusal is legitimate;
- when in public institution refuse to serve - call the regional TFOMS. The phone number can be found on the website of the Federal Compulsory Health Insurance Fund. It's illegal;
- when health workers claim that they work only with specific insurers, this is also illegal, since the policy is valid throughout the country.
Good to know! Analyzes are a preventive measure, which means an insured event. This is regulated by Art. 3 of the Federal Law No. 326. In accordance with the law, free research to clarify the diagnosis should be carried out throughout the territory of the Russian Federation.
In the event of an incomprehensible situation, call your insurance company - they will tell you how to proceed. The phone is on reverse side policy.
What tests can be taken for compulsory health insurance for free
The problem is that there is no complete and exhaustive list of free CHI studies. Specialists sometimes do not even know whether a particular study falls under the insurance program. This is due to the fact that the diagnosis of various diseases sometimes requires an individual approach. To make a specific diagnosis, there is no need to puzzle over this issue - just look at the standards of medical care.
Remark: the standards of medical care are the selection of minimum effective measures for the diagnosis and treatment of a particular disease.
In order to find out if some type of research is provided for by the CHI program, you must:
- Look at Article 35 of Federal Law No. 326. For example, if it is necessary to diagnose or observe a disease of the eye and its adnexa (for example, astigmatism), this is included in the CHI program.
- Next, we are looking for a standard of medical care for this disease on the website of the Ministry of Health of the Russian Federation. We select the subsection “Diseases of the eye and its adnexa” and look for the Order of the Ministry of Health “On approval of the standard for primary health care for astigmatism”. We open it and look for the desired position in the nomenclature list.
An indicative list of standard analyzes for CHI 2020:
You can see a complete list of analyzes for compulsory medical insurance in 2020.
By eco
Approximately one seventh of married couples in the Russian Federation cannot conceive a child through natural insemination. Often this is due to the peculiarities of the physiological structure of the reproductive organs or the banal incompatibility of partners. Fortunately, the state proposes to solve this problem by providing a quota for IVF, which includes both sexes with infertility.
In order to become parents through in vitro fertilization under the CHI program, it is necessary to undergo a medical examination.
List required list analyzes for IVF according to CHI 2020:
- general and biochemical analysis of blood and general analysis urine;
- fluorographic examination;
- blood sampling to determine the Rh factor and group;
- hysteroscopy and pipel biopsy;
- taking smears for the composition of the microflora from the vagina and from the urethra;
- hemostasiogram;
- blood test for homocysteine;
- hormonal panel: study of the level of hormones: prolactin, TSH, T4, in case of menstrual dysfunction - FSH, cortisol (important to eliminate the stress factor), estradiol, metanephrine and normetanephrine.
- blood sampling to detect TORCH infections (syphilis, HIV, hepatitis, herpes);
- PCR of vaginal discharge for herpes virus and cytomegalovirus;
- microbiological analysis for chlamydia, mycoplasma, ureaplasma is also included in the compulsory medical insurance policy for IVF;
- smear cytology from the cervix and cervical canal;
- detection of antibodies to the rubella virus;
- Ultrasound of the pelvic organs and the thyroid gland;
- Ultrasound of the mammary glands - up to 35 years, mammography - after 35 years;
Research for men:
- blood test for TORCH infection;
- spermogram;
- PCR of discharge from the urethra for herpes virus and cytomegalovirus;
- the CHI policy also includes seeding or PCR for chlamydia, ureaplasmosis, mycoplasmosis;
- taking swabs for flora from the urethra;
- blood sampling for Rh factor and group.
The shelf life of the results of the above studies is from 3 months to one year. If there were unsuccessful IVF attempts or interrupted pregnancies before the procedure, partners are advised to undergo a blood test for a karyotype.
Details about and all sorted out in separate articles on our website.
During pregnancy
Expectant mothers also have the right to conduct tests under the compulsory medical insurance policy. To do this, you must be registered in the antenatal clinic and regularly visit your obstetrician-gynecologist.
The list of standard studies includes:
- clinical blood and urine tests;
- blood chemistry;
- allergen tests (in the presence of skin reactions and mucosal reactions)
- research for the detection of infectious diseases;
- detection of antibodies to viral infections - measles and rubella;
- blood sampling for Rh factor and group;
- blood sampling for TORCH infection;
- hormonal panel: hCG, estrogen, progesterone, prolactin.
If the doctor sees the need for any additional studies, they are carried out on a paid basis only when the clinics providing services under the MHI program do not have the appropriate equipment, tools or reagents.
Refund Policy
It happens that the insured person takes a series of tests on his own initiative, so as not to waste time visiting the clinic. Accordingly, payment for the research carried out is made from his own pocket. In such a situation, it is extremely difficult to justify the need to provide free medical services. There is still a chance to return the money spent, but for this you need to do the following:
- keep all receipts for payment for medical services provided on a paid basis;
- bring them to the insurance company and find out if the study falls under the compulsory medical insurance program;
- if the tests are included in the list of free tests, you need to write an application for a refund and indicate in it the details of your bank account for a refund.
The above algorithm will take effect only when the patient has a referral from a doctor for paid tests. Otherwise, it is almost impossible to return the spent funds, because the state cannot pay for all studies carried out without a referral, and only on the basis of the insured person's own initiative.
Important! In order to prove your case, first of all you need to know your rights. If a doctor or insurer insists that the required analysis is not included in the MHI program, this can be checked on the website of the territorial MHIF or contact regulations. Some unscrupulous health workers deliberately send patients for paid tests, and then get their share for it.
Conclusion
Summarizing the above, the following conclusion suggests itself: almost all tests prescribed by a doctor can be carried out free of charge, because there is simply no exhaustive list. The specialist acts in accordance with generally accepted norms and standards - if a certain study is needed to confirm the diagnosis and this is supported legislative act, then this does not go against the terms of the compulsory insurance program.
The patient, in turn, must: know his rights as an insured person, be able to find information of interest in legislative framework and on sites, have a policy with you and decide everything contentious issues with the insurer.
You can learn more about the system and your rights in our next article.
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Russian citizens are guaranteed free health care. A policy is issued to people - a document embodying support state system healthcare in case of illness.
And what does it really mean? What types of services in the clinic are required to provide without additional payment, and for which you have to pay yourself? Under what circumstances is a free medical examination carried out? Let's look at all the questions in detail.
About free medicine
The 41st article of the Constitution of the Russian Federation lists guarantees to citizens of the country from the state. In particular, it says:
“Everyone has the right to health care and medical care. Medical assistance in state and municipal institutions health care is provided to citizens free of charge at the expense of the relevant budget, insurance premiums, and other revenues.
Thus, the list of free medical services should be determined by the relevant state bodies, that is, the healthcare system. This happens on two levels:
- federal;
- regional.
Important! The budget fund for the development of medical institutions is formed from several sources. One of them is tax revenues from citizens.
What types of services are guaranteed by the state
By virtue of the current legislative acts, patients are guaranteed the right to the following types of medical care:
- emergency (ambulance), including special;
- outpatient treatment, including examination;
- hospital services:
- gynecological, pregnancy and childbirth;
- with exacerbation of ailments, ordinary and chronic;
- in cases acute poisoning, in case of injury, when intensive care is needed, associated with round-the-clock supervision;
- planned outpatient care:
- high-tech, including the use of complex, unique methods;
- medical care for citizens with incurable ailments.
Medicines are issued at the expense of the budget to people suffering from the following types of diseases:
- shortening life;
- rare;
- leading to disability.
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New in legislation since 2017
- pre-medical;
- medical;
- specialized.
In addition, the text of the document contains a list of medical professionals who are subject to the obligation to serve patients without charging money.
These include:
- paramedics;
- obstetricians;
- other health workers with secondary specialized education;
- doctors of all profiles, including doctors of family medicine and pediatricians.
Medical policy
Important! Not only citizens of the Russian Federation have the right to issue a compulsory medical insurance policy. It is issued (for a small fee) to foreigners permanently residing in the country.
The MHI policy has the following semantic content:
- the citizen is guaranteed medical support;
- medical organizations perceive it as a client identifier (for it, the hospital will transfer funds from the Compulsory Medical Insurance Fund).
How to get an OMS policy
The document is issued by the relevant companies operating within the framework of the legislation of the Russian Federation. Their rating is regularly printed on official websites, allowing citizens to make their choice.
To be issued a CHI policy, you must provide a minimum number of documents.
Namely:
- for children under 14:
- birth certificate;
- parent's (guardian's) passport;
- SNILS (if any);
- for citizens over 14 years old:
- the passport;
- SNILS (if available).
Important! For citizens of the Russian Federation, the policy is valid indefinitely. Only foreigners are provided with a temporary document:
- refugees;
- temporarily residing in the country.
Rules for replacing the CHI policy
In some situations, the document is supposed to be changed to a new one. These include the following:
- when moving to a region where the insurer does not work;
- in case of filling out the paper with errors or inaccuracies;
- in case of loss or damage to the document;
- when it fell into disrepair (dilapidated) and it is impossible to make out the text;
- in the event of a change in personal data (marriage, for example);
- in the case of a planned update of the sample form.
What is included in the free service under the MHI policy
In paragraph 6 of Article 35 federal law No. 326-FZ provides a complete list of free services under a medical policy provided to document holders. They are provided in:
- polyclinic;
- dispensaries;
- hospital;
- Ambulance.
What can OMS policy holders expect?
In particular, patients are entitled to free medical care and treatment in the following situations:
Dentists, like other professionals, are required to work with clients without pay.
They provide the following types of assistance:
- treatment of caries, pulpitis and other diseases (enamel, inflammation of the body and roots of the tooth, gums, connective tissues);
- surgical intervention;
- dislocations of the jaws;
- preventive actions;
- research and diagnostics.
Important! Services for children are provided free of charge:
- to correct an overbite;
- enamel strengthening;
- treatment of other lesions not related to carious.
How to apply the CHI policy
In order to organize the treatment of patients, they are attached to the clinic. The choice of a medical institution is at the mercy of the client.
It is defined:
- convenience of visiting;
- location (near the house);
- other factors.
How to "attach" to the clinic
You can do this with the help of an insurer (choose an institution when receiving a policy) or on your own.
To attach to the clinic, you should go to the institution and write an application there. Copies of the following documents are attached to the paper:
- identity cards:
- passports for citizens over 14 years old;
- birth certificates of a child under 14 years of age and passports of a legal representative;
- compulsory medical insurance policy (original is also required);
- SNILS.
Important! Citizens registered in another region can legally refuse to attach to a polyclinic if the institution is overcrowded (the maximum norm of patients has been exceeded).
In case of refusal, it should be requested in writing. You can complain about a medical institution to the Ministry of Health of the Russian Federation or Roszdravnadzor.
Visit to the doctor
In order to get help from a specialist, you must register with him through the registry. This department issues admission vouchers. Terms and rules of registration, patient care are established at the regional level. They can be found in the same registry.
In addition, the insurer must provide this information to customers (you need to call the number indicated on the policy form).
For example, in the capital there are such rules for providing patients with medical services:
- referral to an initial appointment with a therapist, pediatrician - on the day of treatment;
- coupon to specialist doctors - up to 7 working days;
- carrying out laboratory and other types of examination - also up to 7 days (in some cases up to 20).
Ambulance
All people in the country can use emergency medical services (the presence of a CHI policy is optional).
There are regulations governing the activities of ambulance crews. They are:
- the ambulance service responds to emergency calls within 20 minutes in case of a threat to people's lives:
- accidents;
- wounds and injuries;
- acute illnesses;
- poisoning, burns and so on.
- emergency care arrives within two hours if there is no threat to life.
How to call an ambulance
There are several options for seeking emergency medical care. They are:
- From a landline, dial 03.
- By mobile connection:
- 103;
Important! The last number is universal - 112. This is the coordination center for all emergency services: hide, fire, emergency and others. This number works on all devices if there is a network connection:
- with zero balance;
- with the absence or blocking of the SIM card.
Ambulance Response Rules
The service operator determines if the call is justified. An ambulance will arrive if:
- the patient has signs of an acute illness (regardless of its location);
- there was a catastrophe, a mass disaster;
- received information about the accident: injuries, burns, frostbite, and so on;
- violation of the activity of the main body systems, life-threatening;
- if childbirth or termination of pregnancy has begun;
- the disorder of the neuropsychiatric patient threatens the lives of other people.
Calls due to such factors are considered unreasonable:
- the patient's alcoholism;
- non-critical deterioration of the patient's condition of the clinic;
- dental diseases;
- carrying out procedures in the order of planned treatment (dressings, injections, etc.);
- organization of workflow (issuance of sick leave, certificates, drawing up an act of death);
- the need to transport the patient to another place (clinic, home).
Where to file medical complaints
When conflict situations, rude treatment, insufficient level of services provided, you can complain to the doctor:
- chief physician (in writing);
- to the insurance company (by phone and in writing);
- to the Ministry of Health (in writing, via the Internet);
- Roszdravnadzor (also).
Attention! The term for consideration of the complaint is 30 working days. Based on the results of the check, the patient is required to send a reasoned response in writing.
If necessary, the attending doctor can be changed to another specialist. To do this, write an application addressed to the head physician of the hospital. However, the change of specialists is allowed to be carried out no more than once a year (except in cases of relocation).
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Last changes
On May 28, 2019, new compulsory medical insurance rules came into force, according to which it is envisaged the introduction in Russia of policies of a single sample (paper or electronic format). At the same time, there is no need to replace the previously issued policy. In addition, if it is technically possible to unambiguously identify the insured person in the unified register of insured persons, then instead of the CHI policy, a passport can be presented (Order of the Ministry of Health of Russia dated February 28, 2019 No. 108n “On Approval of the Rules for Compulsory Medical Insurance“).
The new Rules provide for stricter control over the observance of the rights of the insured, as well as close electronic interaction between the territorial MHIF, insurance organizations and medical organizations:
- polyclinics every year until January 31 will have to report to the TFOMS (through a single portal) the number of those attached, the number of people under dispensary observation, schedules of professional examinations / medical examinations with a quarterly / monthly breakdown by therapeutic areas; work schedules);
- polyclinics every day on working days before 9 am must report (through the TFOMS portal) on insured persons who have passed a medical examination, as well as on persons undergoing medical examination;
- medical organizations, a medical insurance organization (HIO) and TFOMS will exchange information in electronic form every day on the TFOMS portal: hospitals must update data on the implementation of medical care volumes, free beds, accepted / non-admitted patients by 9 am; polyclinics update information on hospital referrals issued yesterday until 9 am; medical organizations that provide specialized, including high-tech, medical care, post information about patients who have had a telemedicine consultation, and the CMO is obliged to monitor the implementation of the recommendations received from the NMIC doctors, and has the right to conduct an in-person examination within the next 2 working days ;
- regardless of the mentioned interaction, every day no later than 10 am, the CMO informs hospitals about patients referred to such hospitals the day before, and also every day no later than 10 am informs medical organizations about the number of free beds in the context of profiles / departments, about patients whose hospitalization did not take place;
- On the basis of the database from the TFOMS portal, the HMO checks during the working day whether the patients were correctly referred to specialized medical organizations. If hospitalization took place out of time, not according to the profile, the HMO must file a complaint with the head physician of the violating medical organization and the regional Ministry of Health, and, if necessary, take measures and transfer the patient;
- insurance representatives of HIOs received a wide range of responsibilities - working with citizens' complaints, organizing examinations of the quality of medical care, informing and accompanying them when providing them with medical care, inviting them to medical examination, monitoring its passage, forming lists of "persons for medical examination" and lists of citizens who fell under the dispensary observation;
- patients will be able to see when and what medical services were provided to them, and at what cost: in personal account on the portal of public services or through the TFOMS - by means of authorization in the ESIA;
- for oncological patients, the HMO undertakes to create (on the TFOMS portal) an individual history of insurance events (based on registers-accounts) throughout all stages of medical care.
The updated CHI Rules directly impose on the CMO the obligation to carry out pre-trial protection of the rights of insured persons. When they file complaints about poor-quality medical care or charging for services under the compulsory medical insurance program, the CMO registers written appeals, conducts a medical and economic examination and an examination of the quality of medical care.
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Under the MHI policy, you can take tests for the diagnosis and treatment of most diseases for free. Forcing a patient to pay for tests in most cases is illegal, but in order to avoid unnecessary expenses or return funds for paying for procedures in public clinics, it is necessary to know the legal basis for the interaction between medical institutions, their patients and the insurance company.
What tests can be taken for free
The procedure for providing citizens with free medical care under compulsory medical insurance policies is regulated by the following regulations:
- Law No. 326;
- Decree No. 1403;
- the laws of the subjects of the Russian Federation.
All citizens of the Russian Federation who have received a compulsory medical insurance policy are guaranteed medical care, both under the basic and additional (regional) programs. The main program includes not only the treatment of pathologies established by the doctor, but also the timely detection of such pathologies, as well as preventive measures.
The list of diseases subject to free therapy throughout the Russian Federation is briefly presented in paragraph 6 of Art. 35 of Law No. 326, and in more detail is given in the List of Section 4 of Decree No. 1403.
Free analyzes are prescribed for the following purposes:
- treatment of the pathology present in the List;
- diagnosis of this pathology;
- diagnosis of possible comorbidities;
- prevention of suspected pathology and concomitant diseases.
For example, a doctor, based on the symptoms described by the patient, suspects a specific pathology, which is often accompanied by another pathology. If tests for the presence of the underlying disease are free, then tests for the presence of a concomitant disease must also be performed as part of the services paid by the insurance company.
The main medical standards for the treatment of diseases listed in the basic and additional programs can be viewed on the website of the Ministry of Health of the Russian Federation.
Among the main free types of analyzes are the following:
- blood test for syphilis - markers, HIV, and other infections;
blood and plasma tests for the content of the main elements (red cells); - biochemical studies of blood and lymph;
- analysis of the content of hormones;
- tissue biopsy;
- high-tech analytical studies of tissues and organs (MRI, CT);
- x-ray studies;
- ultrasound analyzes of tissues and organs;
- scrapings and smears of the skin, foreskin and saliva.
Paid can only be expensive analyzes in case of suspected rare autoimmune or genetic diseases, which occur less frequently than in 0.01% of cases, as well as aesthetic medicine analyzes.
How to check if analysis is free
To determine the legality of sending a doctor to take paid tests, you need to find out if the necessary analysis is included in the list of services provided under the basic insurance program.
It is important to know that the basic list of medical services provided throughout the country can be supplemented by:
- regional medical programs;
- employer programs.
Regional programs are budget subventions for paying for services that are not on the All-Russian list, and which are provided free of charge only in a specific subject of the federation. Only patients who are registered in the region and have received an insurance policy from local insurers can receive these services.
In addition, large employers paying insurance premiums for their employees, can provide additional packages free examination services.
To check the possibility to pass the analysis prescribed by the doctor for free, you need to perform the following steps:
- View the presence of the pathology suspected by the doctor in the main list approved by Resolution No. 1403.
- In the absence of a disease in this list, find out if it is in the list of services provided by the insurers of the given region or the patient's employer.
- Find out the list of tests necessary for the diagnosis and treatment of this disease from the standards on the website of the Ministry of Health.
The list of additional regional services can be viewed on the website of the regional Ministry of Health, and the services provided under insurance from the employer are listed in the appendix to the employment agreement.
If the diagnosed disease is in one of the free programs, and the prescribed tests are included in the standard for the treatment of this disease determined by the Ministry of Health, then the patient has the right to take this test for free.
How to get a referral
At the initial appointment, the patient is often given a referral for tests to a paid clinic under the pretext of absence necessary equipment or reagents in this clinic. It is important to know that only the patient has the right to choose where medical services are provided. The doctor can only issue a referral for analysis, and the place of delivery and processing of the results is determined by the patient.
Getting a referral for free tests is as follows:
- the patient goes to a specialist doctor to diagnose the disease;
- the doctor determines which tests the patient needs to pass and issues a referral;
- if it is not possible to conduct an analysis in this clinic, the doctor issues a referral to another medical institution;
- if the clinic employee refuses to give a referral for a free analysis, it is necessary to write a complaint addressed to the head or chief physician.
If the appeal to the management of the clinic did not bring results, and the necessary analysis is included in the list of basic or regional services provided under the CHI policy, then the patient should contact the representative of his insurance company.
You can contact using hotline, and personally, to the representative office of this insurer in the locality. Most insurance companies have special departments, whose work is aimed at resolving conflicts between medical institutions and patients.
If, after the attempts made, a referral for a free analysis is not received, then you should contact regional fund medical insurance. Such funds monitor the activities of private insurers in the context of respecting the rights of insured patients.
In some cases financial resources, spent by the patient on the delivery of free tests can be returned. You can return funds in 2 ways:
- at the cash desk of the clinic;
- in an insurance company.
If the patient was referred for a paid analysis at the treatment clinic, then to return the funds, you need to do the following:
- draw up an application addressed to the head physician for the return of funds;
- attach to the application a check for payment for tests and an agreement on the medical services provided;
- receive an order-resolution on the payment of compensation;
- apply with a copy of the order and a passport to the accounting department of a medical institution.
The application indicates the full name of the patient, his address at the registration and passport data, then you need to state the reasons for the return of funds, indicate the amount spent and the number of the insurance policy. The basis should indicate the presence of the passed analysis in the basic list of services that holders of compulsory medical insurance policies can apply for.
For a refund, you must keep a receipt for payment for services and an agreement on paid services.
If the patient was referred to private clinic for testing, the return of the money spent is carried out through the insurer that issued the policy. To do this, you must contact the representative office of the insurance company of the municipality and draw up an application for a refund based on the occurrence insured event- the need to submit an analysis from the basic or additional lists.
Transfer of money through the insurance company is usually carried out within 3-8 business days. If the employer pays the contributions for the CHI policy, then the compensation can be transferred through the cash desk of the enterprise or to a salary card.
Difficult situations
When applying for compensation or when requesting a referral to another medical facility, the patient may experience a refusal or a severe delay in responding to the appeal. In most cases, the situation is resolved by a call to the specialists of the insurance company that issued the policy, or a complaint to the regional MHI fund.
If the prescribed tests are included in the basic list and are an expensive procedure, then the patient has the right to demand the provision of this service free of charge through the judicial authorities. It is important to consider that referral for tests to another locality or a paid clinic can only be issued under the following circumstances:
- the inability to conduct these studies in public clinics of the municipality;
- the absence at the moment of the necessary specialists in the clinic;
- the absence of an assigned analysis in the basic and additional lists of free services;
- application of a person from another region for a service provided within the framework of the program of the subject of the federation.
The doctor must inform the patient about the free equivalent of any medical service provided. Often, patients are deceived by giving a referral for paid tests with the promise of subsequent compensation, to which the patient will not be entitled due to a personal waiver of demons. paid service.
To avoid such deception, you need to carefully review the contract offered for signing when passing paid analyzes for the presence of a clause on the refusal of a free service. In the presence of this item, the money spent can be returned only by a court decision.
If the patient, when providing a paid service, is refused to issue a contract and a check, you need to refuse to pay and file a complaint with the head doctor and the insurance company, since these actions of the staff are illegal.
Conclusion
Most of the tests in public clinics can be taken by holders of compulsory health insurance policies free of charge. In order to exercise your rights, you should look for the prescribed analysis in the list of free services and, if necessary, require referral to another medical institution, and in order to return the money spent, it is important to keep a copy of the contract and receipt. Majority difficult situations resolved by contacting representatives of the insurance company.
Often tax officials question the reality of services. AT Clause 5, Article 38 of the Tax Code of the Russian Federation It is written: “A service for taxation purposes is recognized as an activity, the results of which have no material expression, are realized and consumed in the process of carrying out this activity. Therefore, sometimes it becomes very problematic to prove the reality of the service provided ...
Situation: Petrushka LLC ordered cleaning services from a cleaning company. For a couple of months, until a cleaner is hired in the state. How to prove to the tax authorities that the cleaner Glasha daily washed the floors, windows, dusted and took out the trash? Take pictures of Glasha in the process of providing cleaning services? Or, for greater security, Glasha should provide a daily report on the number of floors washed, square meters of dust and garbage bags taken out. To assess the effectiveness of labor and determine whether the quality of the service corresponds to the declared price? It may be absurd, but in proofs of the reality of services, all means are good ...
The company did not achieve the goals, so the reality of the services is in doubt…
The company claimed VAT for consulting services, but was refused by the tax authorities. Employees of the fiscal service suspected the formality of the transactions. And such conclusions were supported by "reasonable" evidence:
- The lack of detailing the services provided under disputed invoices does not allow determining the volume of specifically provided services and their cost;
- The parties to the contract are interdependent;
- The expenses incurred by the company for consulting expenses are not economically justified and are not substantiated;
- Acceptance and delivery certificates for the services provided are formal, identical in content and do not disclose the content business transactions;
- Promotion and sales work is not effective, because the company did not achieve the result indicated in the goals: the increase in sales revenue was supposed to be at least 20%, but in fact it turned out to be 14%. In this connection, the tax authorities came to the conclusion that the terms of the agreement to ensure an increase in sales revenue were not fulfilled.
However, the company insisted on the validity and reality of the consulting services provided:
- A contract was concluded between the company and the counterparty, which indicated economically justified goals (creating a system for the effective management of the company, ensuring the most efficient management of the use of production, financial and other resources involved in the economic turnover, achieving target indicators for the financial and economic activities of the company);
- The Company provided documents: certificates of acceptance and delivery of services rendered, containing the list and scope of services rendered, as well as their cost, invoices;
- CEO and Chief Accountant the counterparty confirmed the reality of the provision of services;
- Consulting took place by exchanging electronic messages (a list of incoming and outgoing messages is presented) and referrals of employees with official assignments (travel certificates, official assignments, etc. are presented).
More details gentlemen!
However, the court considered the arguments of the tax authorities more convincing:
- According to Art. 105.1 of the Tax Code of the Russian Federation the companies are interdependent, and this fact had an impact on the terms and results of the transaction;
- Invoices do not meet requirements pp. 5 p. 5 art. 169 Tax Code of the Russian Federation, since they do not contain a description of specific work performed, services rendered;
- The invoices and acceptance certificates submitted by the company do not disclose the content of business transactions, the acts contain only general information regarding the services provided: they do not contain references to the reports of performers, information on who and what specific consultations were carried out or provided specific services, there are no data on pricing and determining the cost for specific types of services rendered, there are no protocols for agreeing on a contractual price.
Therefore, on the basis Definitions of the Armed Forces of the Russian Federation No. 308-KG16-14980 dated 11/15/2016 proved the economic unjustification and unreasonableness of the presentation for VAT deduction for consulting services.
I turned to the lawyers of the Tours and Partners company with the question: “How to prove the reality of services / works? After all, if the product can be touched, counted, photographed, then it is almost impossible to touch the service or work ... ”And you can find fault, if you wish, with anything ...
Ramazan Chimaev, lawyer and tax consultant"Tours and partners":
To recognize the interdependence of persons, the influence that may be exerted due to the participation of one person in the capital of other persons, in accordance with an agreement concluded between them, or if one person has another opportunity to determine decisions taken by other persons, is taken into account. At the same time, such influence is taken into account regardless of whether it can be exerted by one person directly and independently or jointly with his interdependent persons recognized as such in accordance with this article.
AT Clause 2, Article 105.1 of the Tax Code of the Russian Federation concrete examples of interdependence are given, but the thing is that in item 7 It is written that the court has the right to recognize persons as interdependent for any other circumstances.
In accordance with Determination of the Constitutional Court of the Russian Federation of June 4, 2007 No. 320-O-P tax legislation does not use the concept of economic expediency and does not regulate the procedure and conditions for conducting financial and economic activities, and therefore the validity of expenses that reduce income received for tax purposes cannot be assessed in terms of their expediency, rationality, efficiency or the result obtained. Due to the principle of freedom economic activity(Article 8, part 1, of the Constitution of the Russian Federation), the taxpayer carries out it independently at his own peril and risk and has the right to independently and solely evaluate its effectiveness and expediency.
Based on the Letter of the Ministry of Finance of the Russian Federation dated June 19, 2015 No. 03-01-18 / 35527 “On conducting an audit of the completeness of the calculation and payment of taxes in connection with transactions between related parties”
In accordance with paragraph 1 of Article 105.17 of the Tax Code of the Russian Federation, the completeness of the calculation and payment of taxes in connection with transactions between related parties is checked federal executive body authorized for control and supervision in the field of taxes and fees (hereinafter referred to as the Federal Tax Service of Russia).
At the same time, transactions that are not recognized as controlled in accordance with paragraph 4 of Art. 105.14 of the Tax Code of the Russian Federation, as well as transactions for which the amount of income does not exceed those established in Article 105.14 of the Tax Code of the Russian Federation sum criteria cannot be the subject of tax control in order to verify the compliance of prices with market prices, both as part of the verification of the completeness of the calculation and payment of taxes conducted by the Federal Tax Service of Russia, and as part of on-site and in-house tax audits.
As for the certificates of acceptance and delivery of services rendered, for the correct accounting of expenses, the certificate of services rendered (work performed) is a very important document. The fact is that if companies have provided production services, an act is necessary. Without it, expenses cannot be confirmed. It directly follows from paragraph 2 of article 272 of the Tax Code of the Russian Federation. But, even if we are talking about oral advice or debt collection services from counterparties, one contract will not be enough. And in this case, in order to avoid claims from the inspectors, it is necessary to acquire an act on the services rendered ( Letter of the Ministry of Finance of Russia dated July 30, 2009 No. 03-03-06/1/503).
By general rule when accounting for the costs of services rendered in primary documentation it should be reflected exactly what services/works were performed. Services can be detailed either in the Act of Services Rendered itself, or in an annex to it, drawn up in the form of a Contractor's Report on the work done. Therefore, if the Acts indicate only the general name of the service (legal services, accounting services), then it would be safer and more correct to request from the contractor a Report on the work performed (detailed) and provide it to the inspectors. The report is signed only by the contractor.
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