HEALTH CARE DELIVERY IN EXCESS OF THE ESTABLISHED VOLUMES: FULFILLING OBLIGATIONS UNDER A COMPULSORY HEALTH INSURANCE OR PRIVATE CONTRACT
Authors:   Kabardino-Balkarian State University named after H.M. Berbekova, Russian Federation, Nalchik, Akhokhova Azis ,   LLC Firm "SEM", Russian Federation, Nalchik, Eshtrekova Svetlana ,   LLC Firm "SEM", Russian Federation, Nalchik, Eshtrekova Amina ,   LLC Firm "SEM", Russian Federation, Nalchik, Tkhabisimova Irina ,   Kabardino-Balkarian State University named after H.M. Berbekova, Russian Federation, Nalchik, Khadzugov Artur ,   Kabardino-Balkarian State University named after H.M. Berbekova, Russian Federation, Nalchik, Bozieva Albina ,   Kabardino-Balkarian State University named after H.M. Berbekova, Russian Federation, Nalchik, Chudopal Sergei ,   Kabardino-Balkarian State University named after H.M. Berbekova, Russian Federation, Nalchik, Bzhikhatlova Marianna ,   Kabardino-Balkarian State University named after H.M. Berbekova, Russian Federation, Nalchik, Mirzantova Alina ,   Kabardino-Balkarian State University named after H.M. Berbekova, Russian Federation, Nalchik
Published: December 2023

Significance. The issue of medical care delivery in excess of the established volume, including by private health sector operating under compulsory health insurance remains a challenge to the medical community. The subject of the study, on the one hand, was the overview of the current situation regarding medical organizations that submit registers of bills and invoices for medical services provided to the insured under the territorial program and insurance medical organizations that refuse to reimburse services in excess of the established volumes. On the other hand, the inability of a medical organization to refuse to provide medical care to citizens who have applied for care. The purpose of the study was to analyze the normative and legal acts that regulate legal relations between participants and subjects of the compulsory health insurance, indicating impossibility or difficulties for the parties to fulfill their obligations to ensure care delivery to the insured under the compulsory health insurance program. Material and methods. Material and methods of the study included an analytical review aimed at studying and analyzing the legal policy, current legal practice, current situation regarding place in the medical service market, including the private health sector, in order to answer the research question. Results. The conducted analysis shows that the main function of medical organizations is to provide medical care to the insured. At the same time, territorial funds are responsible for providing medical care to the insured under the federal compulsory health insurance program, and are to create all conditions to ensure availability of services. The federal legislation does not make the provision of free medical care to a citizen under the compulsory health insurance program dependable upon the planned total volume of services and guarantees the provision of free medical care to the insured in the compulsory health insurance system. When the planned volumes of medical care under the program of compulsory health insurance do not correspond to the actual demand, the excess of these volumes provided by a medical organization cannot be attributed to the financial results of its performance. Conclusion. The foregoing confirms the conclusions that medical services provided in excess of the established volumes are to be considered as insured events and are subject to reimbursement in the stated amount. Accordingly, they cannot be a restriction to realizing the powers to provide medical care to citizens under the program of state guarantees in cases where the volume of medical services provided exceeds the planned one, envisaged by the compulsory health insurance contract. This position will help avoid risks, including reputational ones, and prevent the organizations from filing a lawsuit.