Vladivostok Children's Clinic No. 2

History

2023: Recovery of 7.4 million rubles for fraud with compulsory medical insurance accounts

In May 2023, the Arbitration Court of the Primorsky Territory decided to recover 7.4 million rubles from the Vladivostok Children's Polyclinic No. 2 in the case of fraud with funds from the compulsory health insurance fund (compulsory medical insurance).

The territorial compulsory medical insurance TFCMI of the Primorsky Territory and the insurance medical organization (SMO) "East Insurance Alliance" checked the accounts for 443 cases of outpatient medical care for children diagnosed with COVID-19 in 2021. During the check, it was revealed that in the medical documentation the employees of the clinic indicated the MKB-10 U07.1 code (Coronavirus infection COVID-19, the virus has been identified), while in the bills for payment for medical care the code changed to V34.2 (Coronavirus infection of unspecified localization).

Vladivostok Children's Clinic No. 2

At the same time, the conditions for the provision of medical care changed. The first code assumes that treatment is carried out on an outpatient basis at home, which means that the clinic receives money for patients as part of the per capita funding standard. The code declared as a result means that the treatment is provided in a day hospital/hospital at home and the institution receives payment for the money already received for the attached patients at a separate rate.

As a result, as the inspectors found, the clinic unreasonably received 5 million rubles. For each admitted patient, the money was received in a triple amount: the amount consisted of emergency care in an outpatient setting, treatment in a day hospital, as well as a PCR test. In addition, the institution was fined 2.4 million rubles for violation in the procedure for paying for medical care under compulsory medical insurance.

The polyclinic's argument that it legally chose the V34.2 diagnosis code (treatment in a hospital) with reference to the order of the Ministry of Health of the Primorsky Territory was rejected by the court as unreasonable due to the following: in the course of studying the medical records of patients who were initially presented with the U07.1 diagnosis code, the latter, due to mild treatment of the disease, refused to provide medical care in inpatient conditions in the treatment of the new coronavirus infection COVID-19 and gave their consent to provide medical care on an outpatient basis and comply with the isolation regime in the treatment of the new coronavirus infection COVID-19.^[1]

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