MGFOMS failed to challenge the decision to pay for treatment of nonresident Fresenius patients

2021: MGFOMS failed to challenge the decision to pay for treatment of nonresident Fresenius patients

On June 22, 2021, it became known that Ninth Arbitration Court of Appeal it had rejected the complaint (Moscow City MHI Fund MGFOMS), which was trying to challenge the decision of the first instance - back in 2020, the fund was ordered to pay 3.92 million for rubles medical care provided Fresenius Medical Care to nonresident patients. One of the key arguments of the defendant was that (Center LLC Fresenius) did not dialysis conclude an agreement with the fund on the provision of medical care to non-residents, although there is no document of this format, the court emphasized.

Photo: yugtimes.com

We are talking about bills for medical care provided back in 2018 in Moscow to patients insured in other regions. In addition to claims that the documentation was provided in paper, and not in electronic form, MGFOMS stated that the company did not have an agreement on the provision of medical services to non-residents, respectively, the bills would not be paid.

The Moscow Arbitration Court explained that the existence of such agreements is not provided for by law and the fund is obliged to pay for medical care, according to part 8 of Art. 34 of Federal Law No. 326 "On compulsory medical insurance," and after that, according to the scheme of inter-territorial settlements, recover from the fund the territory from where the patient arrived for treatment in the capital. MGFOMS did not agree with this decision.

However, this thesis was confirmed in the appellate instance, which indicated that MGFOMS has legal grounds for reimbursing its expenses from the territorial funds of other constituent entities of the Russian Federation.

"The Court of Appeal also takes into account that in this case, the company provided urgent services for renal replacement therapy (hemodialysis) in connection with the presence of patients in the territory of another subject of the Russian Federation for forced reasons, the interruption of medical care could lead to a fatal outcome for patients," the decision emphasizes.

Payment of medical bills for patients insured outside the region in which they were treated is often the subject of arbitration. For example, in mid-March 2021, the Tenth Arbitration Court of Appeal upheld two decisions of the Moscow Region Arbitration Court in favor of companies included in the United Medical Systems Group of Companies to recover almost 270 million rubles from the regional TFCMI for non-resident medical care.^[1]

2020

MGFOMS appealed the court decision to pay for the treatment of nonresident patients Fresenius

On April 23, 2020, it became known that the Moscow City MHI Fund sent an appeal against the decision of the Moscow Arbitration Court: in March 2020, the Dialysis Center company, which manages the metropolitan points of the Fresenius Medical Care network, managed to recover 3.92 million rubles. The fund owed so much for renal replacement therapy, which in 2018 patients from other regions underwent in network centers.

According to the case file, MGFOMS motivated the refusal to pay for the treatment of patients of the Dialysis Center with various arguments. Including, MGFOMS suggested that these patients could come from the Moscow region, in the implementation of the program of which at that time the "Dialysis Center" participated. The court also did not accept this argument and satisfied the claims of the plaintiff^[2]

Fresenius sued MGFOMS for 3.9 million rubles for the treatment of patients from other regions

On March 20, 2020, Zdrav.Expert learned that the Moscow Arbitration Court upheld the claim of the Dialysis Center company, which manages the capital's points of the Fresenius Medical Care network, to recover 3.9 million rubles from the Moscow City OMS Fund (MGFOMS). The fund owed so much for renal replacement therapy, which in 2018 patients from other regions underwent. In court, the representative of the MGFOMS unsuccessfully referred to the fact that patients could arrive from the Moscow region, in the program of which the Dialysis Center then participated, which means that the bills for this medical care were intended for the Moscow Region terfond.

Fresenius Medical Care Dialysis Center

According to the case file, in 2018, the Dialysis Center sent invoices to MGFOMS for medical care in the amount of 3.99 million rubles. The fund's specialists conducted medical and economic control of the documents and paid only a small part, and 3.92 million were refused compensation. At first, the refusal was explained by some defects in the materials submitted, then they stated that the company did not have an agreement on the provision of medical services to patients insured outside Moscow. The court declared this argument insolvent, explaining that the existence of such agreements is not provided for by law and the fund is obliged to pay for medical care, according to part 8 of Art. 34 of Federal Law No. 326 "On compulsory medical insurance," and then request compensation for expenses under the scheme of inter-territorial settlements (MTR) from the fund of the territory from where the patient arrived for treatment in the capital.

Already in court, representatives of the MGFOMS cited other counter-arguments, which, however, also did not work. Firstly, according to MGFOMS, the accounts were provided on paper, which did not allow to fully carry out medical and economic control.

Secondly, the lawyer of the fund petitioned to bring to the case as a third person TFCMI Moscow Region.

Given the fact that the plaintiff was included in 2018 in the terprogram of both the city of Moscow and the Moscow region and requires payment for medical services that were provided to a certain category of citizens whose insurance affiliation cannot be revealed, it is necessary that the Moscow Region Fund provide an explanation that these are not his insured, "the representative of MGFOMS explained at a meeting on February 13, 2020.

The judge refused to grant this application, and the plaintiff's claims, on the contrary, fully supported.

The Dialysis Center company is the holder of medical licenses of at least five Moscow points of the Fresenius network. By, to data SPARK-Interfax the organization is 100% owned by the German Fresenius Medical Care Beteiligungsges. The Moscow Dialysis Center has been part of the network since 2002, and it was founded in 1999 by pop singer, Honored and People's Artist of the RSFSR Lev Leshchenko. Co-investors of the project, according to information Moskovsky Komsomolets, were the companies Euromedic Investmens, Shreya and comedian Vladimir Vinokur. The revenue of the Dialysis Center in 2018 amounted to 720.98 million rubles, a net loss of 312.7 million rubles.

According to the Vademecum Analytical Center, in 2019, metropolitan medical institutions provided medical care for compulsory medical insurance to patients insured in other regions for 26.9 billion rubles. At the end of 2019, MGFOMS faced billions of dollars in debt under the MTR. According to Vademecum, other regions owed the capital about 13 billion rubles. Natalya Stadchenko, ex-chairman of the Federal Compulsory Medical Insurance Fund, explained what happened by incorrect planning of the MTR in the regions and promised to monitor this situation in the future. Having replaced her Elena Chernyakova , the task was also set to deal with the problem of the MTR, Ministry of Health RUSSIAN FEDERATION and the working group of the State Council on to health care it should work out the same issue by May 1, 2020 on behalf of the president. Vladimir Putin

The Russian The representative office of Fresenius Medical Care, which as of March 2020 includes Fresenius SP CJSC, Fresenius Nefrokea LLC, Dialysis Center LLC, is a major dialysis service provider in the country, uniting 66 points in 43 regions. Every year, about 8 thousand patients undergo treatment at Fresenius centers (more than 1.2 million renal replacement therapy procedures per year). FMC revenue in, Russia according to SPARK-, in Interfax 2018 exceeded 7.51 billion rubles, net profit - 505 million rubles^[3]

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