Insurance representatives

Main article: Compulsory health insurance (Compulsory health insurance)

Institute of insurance representatives – the federal project implemented by medical insurance companies with assistance of Federal Compulsory Health Insurance Fund and the Russian Ministry of Health since 2016 – then there began work insurance representatives of the I level. Since 2017 insurance representatives of the II level, and in 2018 – insurance representatives of the III level were entered.

The state develops the system of protection of the rights of patients on the basis of medical insurance companies as parts of a system of compulsory health insurance. The number of insurance companies in 2019 sharply decreased from 150 to 35. According to the Ministry of Health, for November, 2019 more than 14 thousand specialists are employed in institute of insurance representatives.

Insurance representatives of the I level: informing, help, polls

The insurance representatives of the I level provided by the staff of contact centers of medical insurance companies began work in July, 2016. The main objective of these specialists – providing on oral citizens' appeals of information of help character concerning compulsory health insurance. Treat their tasks:

• Consultation of citizens about their rights and opportunities in the compulsory health insurance system;
• Informing on need of passing of medical examination, dispensary observation and routine inspections;
• Holding polls, including, about quality of provision of services by the medical organizations.

Insurance representatives of the II level: permission of disputable situations, consultation

Insurance representatives of the II level were entered in January, 2017. They work with specific addresses of the insured persons, take measures for recovery of their legitimate rights at the request for medical care. Treat their tasks:

• Participation in permission of the disputable situations arising between the insured person and the medical organization at delivery of health care, for the purpose of taking measures, directed to observance and recovery of the rights insured;
• Consultation on issues of receiving different types of medical care, including specialized highly skilled help;
• Informing on preventive actions, accounting and control of their passing;
• Control of the organization of planned hospitalization;
• Medical examination passing control;
• Individual maintenance of the insured persons with chronic noninfectious diseases, the persons delivered on dispensary observation after delivery of health care permanently with oncological diseases;
• Informing the insured persons on need of timely passing of dispensary surveys;
• Ensuring interaction of insurance representatives of all levels among themselves.

Insurance representatives of the III level: specialists with the higher medical education

Insurance representatives of the III level are highly qualified specialists with the higher medical education and work experience in practical health care not less than 5-10 years. Treat their tasks:

• Interaction with the medical organization for results of the carried-out expertizes: to the facts of non-compliance with a profile, violation of terms of the planned hospitalization separate diagnostic and treatment and others to violations;
• Selection of cases of delivery of health care for conducting scheduled thematic examinations, including at probable signs of violations of routing of patients;
• Conducting examination of quality of medical care or medico-economic examination within consideration of addresses of the insured persons.

Quality control of medical aid for cancer patients

Since January, 2019 insurance representatives of the III level exercise quality control of the medical care provided to patients with malignant new growths. The new functionality of representatives of the medical insurance companies (MIC) was entered within implementation of the federal project "Fight against Oncological Diseases", the Health care national project.

Entered new features of medical insurance companies:

Control of availability and quality of the medical care provided to patients with suspicion of an oncological disease and/or with the set diagnosis of an oncological disease and also selection of such cases for conducting examinations of quality of medical care (including using multidisciplinary approach), medico-economic examinations:

• Control of timeliness of delivery of health care from the moment of suspicion and diagnostics of a malignant new growth until providing specialized, including hi-tech, medical care and also when carrying out dispensary observation, and in cases of exacerbation of an oncological disease;
• Control of compliance of a stage of an oncological disease to the treatment method selected by the medical organization;
• Control of extent of achievement of the planned result when carrying out chemotherapy;
• Information maintenance of the insured persons with oncological diseases.

Medical insurance companies the personified "History of addresses of the patient behind medical care" in case of suspicion on a malignant new growth or with the set oncological disease forms. In the automated mode selection of insured events for monitoring procedure of volumes, terms, quality and conditions of the provided medical care on compulsory health insurance is performed. By its results the insurance representative of the III level should organize and/or carry out medico-economic expertize or examination of quality of medical care, including using multidisciplinary approach.

In addition, insurance representatives of the II level will be engaged in individual information maintenance of patients with oncological diseases.

Main goals of innovations are:

• Quality control, availability (including timeliness) medical care;
• Quality management of the medical care provided to patients at suspicion on a malignant new growth or with the set oncological disease.

When to address insurance representatives

In case of the questions connected with rendering services in the medical organization address, please, to administration of the medical organization or to an insurance representative of the medical insurance company which issued you the policy of compulsory health insurance. It is especially important to get timely advice and the help of an insurance representative in situations when:

• you doubt quality of the provided medical care;
• in the situation connected with long waiting of receiving medical care;
• in case of the offer to pay medical services which should be provided free of charge, etc.