Examination by experts
Medical and economic examination carried out by our specialists and experts with years of experience in the field of voluntary health insurance.
Our employees implement the following kinds of control:
is the establishment of conformity details about the medical assistance volumes rendered to the insured persons on the basis of provided by organization for payment medical registers bills on the conditions of contracts for rendering and payment for health care program, ways of payment for medical services and rate of charge to pay for health care services.
Under medical and economic control is carried out monitoring of all medical assistance in order to:
- check registers bills on conformity to the established order of information exchange.
- identification of insured person a particular health insurance company (payer);
- verify conformity of medical care provided:
- health insurance program;
- conditions of the contract for rendering and payment of health care;
- valid license of the medical organization for realization of medical activities;
- checking the validity of tariff application for medical services, calculation of their value in accordance with the method of calculation rates to pay for health care, ways of payment for medical help and tariffs to pay for health care services, and for rendered by the agreement medical assistance and payment for health care;
- establishment of absence of the excess amounts of medical care services by organization.
Medical and economic expertise
is the establishment of correspondence to the actual timing of medical care, the volume presented for payment of medical services records in primary healthcare documentation and reporting documentation of the medical organization.
Medical and economic expertise is carried out as:
- relevant medical and economic expertise;
- planned medical and economic expertise.
Relevant medical and economic examination is carried out in the following cases:
- repeated appeals regarding one and the same disease: within 30 days - in providing of outpatient;
- polyclinic care, within 90 days - if hospital readmission;
- diseases with elongated or shortened period of treatment more than 50 percent of the established standards
- health care or average realized for all insured persons during the reporting period with a disease for which there is no approved standard of care;
- receiving complaints from the insured person or its representative on the availability of health care in the medical organization.
During planned medical and economic expertise are estimated:
- The amount of provided health care assistance by the organization and its conformity to the insurance program.
- the frequency and nature of violations of medical organization about formation registers of accounts.