Paid medical institutions. Paid health care services. social tax deduction

04.11.2019

16.06.2017

Rules for the provision of paid medical services by medical organizations

The procedure for the provision of paid medical services is regulated by the Federal Laws “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” and “On the Protection of Consumer Rights”.

Internal regulations governing the provision of medical care on a reimbursable basis are signed by the head physician of the medical institution. The provision of paid services must be included in the Charter of the health facility. In addition, the organization must have a license for this type of activity issued by the relevant authority.

The rules for the provision of paid medical services by medical organizations are established at the level of the Government of the Russian Federation and are regulated by two fundamental documents - the Federal Laws "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" and "On the Protection of Consumer Rights".

Provision of paid services: basic information

The main source of funding for healthcare facilities at the state and municipal levels is the budget. Therefore, they have the right to direct the funds received from paid services to satisfy their own needs or to other socially useful purposes and activities.

Internal regulations governing the procedure are signed by the head physician of the health facility. In doing so, you need to remember that:

conducting commercial activities must be entered into the charter of the medical organization;
prices and tariffs for medical services provided by budgetary health facilities are set by regional or federal health authorities.

From January 1, 2013, the basis for the provision of paid services by budgetary clinics and hospitals is the List of works (services) that make up medical activities and are specified in the license for medical activities.

The procedure and rules for the provision of paid medical services by medical organizations should be clearly and in detail communicated to their consumers. General provisions are posted on the official website of the institution on the Internet, as well as on information stands and racks in the public domain.

The following information about commercial services is provided to the consumer:

Conditions.
Forms.
Payment order
Prices and tariffs.

Issues of conditions, forms, procedure for paying for paid medical services in a particular medical institution are established by its charter and are within the competence of the management. The executive authority of the organization may be sole (head doctor) or collegiate (head doctor and his deputies).

Provision of commercial services during regular business hours

The staff of the medical institution has the right to provide paid medical services during their main working hours. However, there are a number of nuances that cannot be ignored. The first and main one is that the management of the organization must adhere to the rules of remuneration for the provision of paid services during the main working hours.

State and municipal health care institutions perform state tasks, exceeding the volumes of which is the basis for the provision of services on a commercial basis.

In addition, the law does not prohibit additional activities during regular working hours. Such activities include paid services that can be provided to citizens in addition to the main task.

Within the framework of compulsory medical insurance, only the volumes of medical care that were established by a state or municipal assignment or by a decision of the commission for the development of the compulsory medical insurance program are subject to payment.

It depends on the number of staff of the institution and the planned indicators of the work of physicians. If these indicators are exceeded, the suspension of the provision of medical care on a free basis is permissible.

Planned medical care

Planned medical care is provided to citizens as part of prevention, as well as for diseases and conditions that do not currently pose a threat to life, and therefore do not require urgent intervention. Let's allow the transfer of planned intervention in terms of time.

For this reason, in some cases it is possible to provide during the main working hours. But at the same time, the duration of waiting for planned assistance cannot exceed the time limits established by the program of state guarantees.

For violation of this paragraph, an administrative fine may be imposed on the LPU.

emergency medical care

If a patient needs emergency intervention, the doctor does not have the right to refuse to provide paid services during his working hours. In this case, assistance to commercial patients is denied on a priority basis, but first they eat, and only then - free of charge.

Refusing to provide emergency care to a patient is against the law, and the availability of payment does not play any role here. The patient can pay for medical services at will or under a voluntary medical insurance contract.

In some cases, doctors are allowed to work during regular hours and when providing assistance to patients who are on inpatient treatment. For example, we can talk about combining positions, which is regulated by Article 151 of the Labor Code of the Russian Federation.

For example, a nurse, along with 20 free patients in a hospital, can provide assistance to a patient occupying a paid bed.

Physician salary during regular working hours

According to the Labor Code of the Russian Federation, an employee, along with the main job in the specialty, may be entrusted with additional work in the same or another profession. Such work is paid separately.

It is possible to combine the main and additional activities, if we are talking about different specialties. Additional work in the same profession is carried out by increasing the volume of work or expanding service areas.

The same rule applies to .

Any additional doctor's work must be paid. The amount of the additional payment is established by agreement between the chief physician and the specialist and depends on the scope and content of the work.

In order for the combination of positions to be possible, the staff of the medical institution must have a vacant wage fund, as well as vacant jobs financed through the provision of commercial services.

The staffing table is set by the head of the medical organization, so he has the right to lead the appropriate positions. This also applies to positions entered at the expense of services provided on a paid basis.

If there are no vacancies in the institution, it is permissible to issue payments for the provision of paid medical services in the form of incentive allowances. However, this possibility should be specified in local regulations with the reference that these payments are introduced within the framework of an effective contract.

According to the rules for the provision of paid medical services by medical organizations, payment for their provision both during regular and additional working hours is possible if the rights of citizens to free medical care are not violated. Therefore, it is always necessary to make sure that the provision of commercial services during regular business hours will not lead to possible violations.

For example, instead of patients who came for help under the state guarantees program, paid patients are accepted. As a result, the first ones are forced to sit in a queue or even go to another day or to another health facility.

various financial violations - for example, remuneration from the funds of compulsory health insurance in case the doctor did not fulfill the plan, but at the same time accepts paid patients.

Restrictions on the provision of paid medical services

The head of the health care institution is responsible for organizing the provision of medical care. He decides whether or not to allow the provision of paid services in a given situation, and also considers all existing restrictions.

Restrictions on the provision of paid services by a medical institution during working hours:

if the doctor does not fulfill the plan for providing free medical care to the population, then additional charges may be reduced or not charged at all;
the doctor is paid only for the work related to the provision of paid services that is performed in excess of the plan (in this case, the total number of services provided on a paid and free basis is summed up);
if planned indicators are not met, regular positions under the MHI or the budget may be reduced;
if the plan for the main position is not fulfilled, the provision of paid services to the doctor may be paid at reduced rates.

One of the sources of financial support for state and municipal health care institutions is income from the provision of paid medical services.

Legal basis for the provision of paid medical services in healthcare institutions

Health care institutions are non-profit organizations, and non-profit organizations, in accordance with Art. 50 of the Civil Code of the Russian Federation, can provide paid services, if it is provided for by their constituent documents, only insofar as it serves to achieve the goals for which they were created, and if it corresponds to such goals.

The right and conditions for the provision of paid services by medical organizations

One of the sources of financial support for state and municipal health care institutions is income from the provision of paid medical services. Health care institutions are non-profit organizations, and non-profit organizations, in accordance with Art. 50 of the Civil Code of the Russian Federation, can provide paid services, if it is provided for by their constituent documents, only insofar as it serves to achieve the goals for which they were created, and if it corresponds to such goals.

In practice, this means that in all documents regulating the provision of paid medical services, it is necessary to indicate in the preamble that such activities are carried out with the aim of wider coverage of the population with quality medical care, the introduction of advanced medical technologies, etc. The provision of paid medical services should never be justified. medical services by insufficient financial support of the health care institution.

From January 1, 2015, one more condition appears for non-profit organizations that carry out income-generating activities in accordance with the charter - their property, with the exception of property of state institutions, must have a market value of at least the minimum amount of the authorized capital provided for limited liability companies , i.e. today - 10 thousand rubles ..

The right of citizens to receive paid medical services provided at their request when providing medical care, and paid non-medical services (household, service, transport, etc.), is enshrined in the Federal Law of November 21, 2011 No. health of citizens in the Russian Federation" (hereinafter - Law No. 323-FZ). At the same time, paid medical services are provided to patients at the expense of their personal funds, employers' funds and other funds on the basis of contracts, including voluntary medical insurance contracts.

Despite the fact that, according to the Accounts Chamber of the Russian Federation, the standards of medical care are approved for only 17% of diseases in which medical care is provided in a hospital, paid medical services can be provided both in full standard of medical care, and in the form of individual consultations or medical interventions, including in excess of the standard.

For medical organizations participating in the implementation of the program of state guarantees of free provision of medical care to citizens and territorial programs of state guarantees of free provision of medical care to citizens (hereinafter - SGBP), Law No. 323-FZ states that they have the right to provide paid medical services to patients:

On other terms than those stipulated by the SGBP and (or) targeted programs;

When providing medical services anonymously, with the exception of cases provided for by the legislation of the Russian Federation (HIV, AIDS, tuberculosis, etc.);

Citizens of foreign states, stateless persons, with the exception of persons insured under compulsory health insurance, and citizens of the Russian Federation who do not permanently reside on its territory and are not insured under compulsory health insurance, unless otherwise provided by international treaties of the Russian Federation;

When applying for medical services on your own, with the exception of the possibility of choosing a doctor and a medical organization in accordance with Art. 21 of Law No. 323-FZ.

It is important to note that the provisions of the Law of the Russian Federation of February 7, 1992 No. 2300-1 “On Protection of Consumer Rights” (hereinafter - Law No. 2300-1) apply to relations related to the provision of paid medical services. Thus, Resolution No. 17 of the Plenum of the Supreme Court of the Russian Federation dated June 28, 2012 established that consumer protection legislation also applies to the provision of medical services to citizens provided by medical organizations within the framework of compulsory medical insurance.

The Federal Law of January 12, 1996 No. 7-FZ “On Non-Commercial Organizations” (clause 4, article 9.2) enshrines the right for budgetary institutions in excess of the established state (municipal) task (as well as in cases determined by federal laws, within the established state (municipal) tasks) to perform work, provide services related to its main activities, to individuals and legal entities on a paid basis and on the same conditions for the provision of the same services.

Let us give an example of the provision of paid medical services within the state assignment.

The state budgetary health care institution "Observation Polyclinic" conducts various types of medical examinations: preliminary, periodic, pre-trip, pre-flight. In accordance with Art. 213 of the Labor Code of the Russian Federation, examinations are paid at the expense of the employer. The body that performs the functions and powers of the founder provides the polyclinic with a subsidy for the maintenance of the institution and, within the framework of the state task, obliges it to provide services to employees of organizations financed from the regional budget at reduced prices.

In accordance with Art. 84 of Law No. 323-FZ, on October 4, 2012, Decree of the Government of the Russian Federation No. 1006 “On Approval of the Rules for the Provision of Paid Medical Services by Medical Organizations” (hereinafter referred to as the Rules) was signed, which entered into force on January 1, 2013.

The Rules for medical organizations participating in the implementation of the SGBP define the conditions for the provision of medical services on a fee basis, including clarification of what “other conditions” are than those stipulated by the SGBP:

In case of inpatient treatment - the establishment of an individual post of medical observation;

The use of drugs that are not included in the List of vital and essential drugs, if their appointment and use is not due to vital indications or replacement due to individual intolerance to drugs included in the specified list, as well as the use of medical devices, medical nutrition, including h. specialized medical nutrition products not provided for by the standards of medical care.

In addition, the Rules repeat the conditions for the provision of paid medical services established by Law No. 21 of Law No. 323-FZ.

In fact, the list of conditions is open. That is, the provision of medical services out of turn, at a convenient time for patients, etc., can still be carried out on a paid basis.

The Rules do not state that, in addition to the types and volumes of the SGBP, medical services are provided only on a paid basis, but in practice this is exactly what happens.

Informing consumers of paid medical services.

Since, we recall, medical services are now covered by Law No. 2300-1, the Rules contain requirements to provide information to consumers in accordance with this law (Articles 9 and 10).

The rules require that the necessary information be posted on the website of a medical organization on the Internet, as well as on information stands (racks) of a medical organization. The obligation of the institution to provide patients with a copy of the license with applications, addresses and telephone numbers of regulatory authorities, information about the mode of operation existed before for review. But from January 1, 2013, it became mandatory to provide a copy of the documents on entering into the Unified State Register of Legal Entities, indicating the body that carried out the state registration; price list - a list of paid medical services with prices in rubles; information about the conditions, procedure and form of providing medical services and the procedure for their payment. As well as the obligation to inform patients about the procedure and conditions for the provision of medical care in accordance with the SGBP, to provide information about medical workers involved in the provision of paid medical services, about the level of their professional education and qualifications. This is due to the fact that Law No. 2300-1 requires the provision of information about the person who will provide the service and information about him, since this is of significant importance to the patient and affects the quality of the service.

Information posted on information stands should be available to all visitors of the institution during the entire time of the medical organization. Information stands should be located in a place accessible to visitors and designed in such a way that it is possible to freely familiarize themselves with the information posted on them. No references to the fact that there are many services, that their prices can be found in the department of paid services or at the cash desk of the institution, which, of course, may not release the institution from the obligation to post the price list on the stand or next to it, even if it is a whole book and visitors periodically "borrow it forever for better study".

The absence in a visual and accessible form on the website of a medical organization in the information and telecommunication network Internet, as well as on information stands (racks) of all the information provided for in clause 11 of the Rules, as well as the text of the Rules themselves and Law No. 2300-1, entails a warning or the imposition of an administrative a fine from 3 thousand to 4 thousand rubles. - on officials; from 30 thousand to 40 thousand rubles. - for legal entities. This is provided for in Art. 14.5 of the Code of Administrative Offenses of the Russian Federation, which establishes such liability for the provision of services by an organization in the absence of information, the obligation to provide which is provided for by the legislation of the Russian Federation.

For familiarization, the consumer (customer), at his request, must be provided with a copy of the charter, constituent agreement, regulation or regulation on the branch, i.e., the constituent documents of the legal entity or its branch that directly provides paid services, as well as information on the introduction of the institution into Unified State Register of Legal Entities.

Informed voluntary consent of the patient

The rules determine that paid medical services are provided with the informed voluntary consent of the patient (clause 28) or his legal representative. Informed consent, which is a prerequisite for any medical intervention, refers to the voluntary decision by the patient to apply a course of treatment or use a diagnostic method after providing the doctor with the necessary amount of information.

Thus, the process of obtaining informed voluntary consent consists of two stages: providing the patient with information at his request and properly processing the patient's consent to receive services.

The patient has the right to receive the following information:

On the state of his health, including information about the results of the examination and the established diagnosis;

Treatment options and the risks associated with each;

Possible options and consequences of medical intervention;

About alternatives to medical intervention;

Expected results of treatment;

Medicines and medical devices used in the provision of paid medical services, including their expiration dates (warranty periods), indications (contraindications) for their use.

Taking into account the principle of voluntary receipt of information, the patient has the right to refuse to receive information or to indicate the person who should be informed about his state of health instead of him. When providing the patient (his legal representative or another person specified by the patient) with information about the upcoming treatment, it is desirable to use a minimum of medical or technical terms, and also make sure that the information is correctly understood.

The obtained consent of the patient to medical intervention must be properly documented. Current legislation does not establish a mandatory written form for processing the consent of the patient. But in the event of a patient-physician conflict or litigation, the patient's written informed consent will protect the institution.

In order to eliminate or, at least, significantly reduce the claims of patients against institutions, it is advisable to develop and approve several forms of documents for various types of medical interventions, samples of which are available in specialized literature and on the Internet.

The document usually consists of two parts - the information part and the patient's own consent to medical intervention. The information part of the document is filled in by the doctor in the presence of the patient or his representative. In the informed voluntary consent (as well as in the contract), it is necessary to indicate that non-compliance with the instructions (recommendations) of the contractor (medical worker providing paid medical services), including the prescribed treatment regimen, may reduce the quality of the medical service provided, entail the impossibility of its completion on time or adversely affect the health of the consumer.

The document must contain the date of signing, as well as a handwritten transcript of the signature of the patient (his representative). A note is also made in the patient's medical record about the availability of informed voluntary consent to medical intervention. A document confirming the patient's informed voluntary consent to medical intervention may be stored in the patient's medical record or separately from it.

When providing paid medical services by medical organizations participating in the implementation of the SGBP, it is necessary to indicate in the informed voluntary consent the reasons why medical care is provided on a paid basis. For example: in excess of the scope of the territorial program of state guarantees of free provision of medical care to citizens; services not included in the SGBP; beyond the standards of treatment; services out of turn; on an anonymous basis, etc. It must be noted that this is done at the request of the patient.

Conclusion of an agreement for the provision of paid services

Please note that in the contract for the provision of paid medical services (which must be concluded only in writing), it is necessary to write “consumer” or “customer”, and not “patient”, as was done before.

Note

A consumer is an individual who intends to receive or is already receiving paid medical services in person in accordance with the contract. But a consumer receiving paid medical services is at the same time a patient covered by Law No. 323-FZ.

A customer is a natural or legal person who intends to order (purchase) or order (purchase) paid medical services in accordance with the contract in favor of the consumer.

At the conclusion of the contract, at the request of the consumer or customer, they must be provided in an accessible form with the following information:

On the procedures for the provision of medical care and the standards of medical care used in the provision of paid medical services;

Specific medical workers providing the relevant paid medical service (their professional education and qualifications);

The methods of providing medical care, the risks associated with them, the possible types of medical intervention, their consequences and the expected results of the provision of medical care.

Consumers or customers may be provided with other information related to the subject of the contract.

It should be noted that prior to the conclusion of the contract, the institution is obliged to notify the consumer (customer) in writing that non-compliance with the instructions (recommendations) of the medical worker providing the paid medical service, including the prescribed treatment regimen, may reduce the quality of the provided paid medical service, entail the impossibility of its completion on time or adversely affect the health of the consumer.

If, in the process of fulfilling the contract, the contractor needs to provide additional medical services to the patient, the parties either sign an additional agreement to the contract, which is an integral part of it, or a new contract is concluded.

It can be recommended, for example, for inpatient treatment, when the cost of providing medical care directly depends on the number of bed-days spent by the patient in the organization, to use the approximate price of the service in the contract.

Example

When treating in a hospital, the approximate price of the service is formulated in the contract after specifying the cost of treatment as follows: “the price of the service is approximate and can be changed upwards or upwards depending on the actual number of days the patient stays in the hospital.” Similarly, the approximate price is formulated for other services, the cost of which depends on the quantity, size, presence or absence of something that cannot be accurately determined before the start of the service.

In accordance with Law No. 323-FZ, if the provision of paid medical services requires the provision of additional medical services for emergency reasons to eliminate the threat to the life of the consumer in case of sudden acute diseases, conditions, exacerbations of chronic diseases, then such medical services are provided free of charge.

If the patient refuses to receive medical services after the conclusion of the contract, the contract is terminated. At the same time, the consumer (customer) is obliged, in accordance with the Civil Code of the Russian Federation, to pay the contractor for the expenses actually incurred by him related to the fulfillment of obligations under the contract.

New options for paying for medical services

Note that the Rules, in accordance with the current legislation, allow issuing not only checks of cash registers, but also other documents of the established form. In other words, when providing medical services at home, at the exit, at a time when the cash desk is not working or the cash register is not working, it is possible to provide paid services and accept payment for them by issuing strict accountability documents equated to checks. At the same time, an agreement on full liability is concluded with employees who accept payment.

New technologies do not stand still, and mobile card readers have already begun to appear, which are connected to smartphones and iPhones, on which appropriate applications are installed and which allow you to pay for services with bank cards even at home and away.

The rules apply not only to services paid for at the expense of citizens' personal funds, but also at the expense of legal entities and other funds on the basis of contracts, including voluntary medical insurance contracts. They determine that the conclusion of voluntary medical insurance contracts and payment for medical services provided in accordance with such contracts are carried out in accordance with the Civil Code of the Russian Federation and the Law of the Russian Federation of November 27, 1992 No. 4015-1 “On the organization of insurance business in the Russian Federation”.

In conclusion, we note that the current legislation does not oblige state and municipal institutions to provide medical care on a paid basis, but enshrines the patient's right to receive such assistance, including in institutions operating under the program (territorial program) of state guarantees of free provision of medical care to citizens. help.

Decree of the Government of the Russian Federation of October 4, 2012 N 1006
"On approval of the Rules for the provision of paid medical services by medical organizations"

In accordance with Part 7 of Article 84 of the Federal Law "On the Basics of Protecting the Health of Citizens in the Russian Federation" and Article 39.1 of the Law of the Russian Federation "On Protection of Consumer Rights", the Government of the Russian Federation decides:

2. Recognize invalid the Decree of the Government of the Russian Federation of January 13, 1996 N 27 "On approval of the Rules for the provision of paid medical services to the population by medical institutions" (Sobranie Zakonodatelstva Rossiyskoy Federatsii, 1996, N 3, Art. 194).

rules
provision of paid medical services by medical organizations
(approved by Decree of the Government of the Russian Federation of October 4, 2012 N 1006)

I. General provisions

1. These Rules determine the procedure and conditions for the provision of paid medical services by medical organizations to citizens.

2. For the purposes of these Rules, the following basic concepts are used:

"paid medical services"- medical services provided on a reimbursable basis at the expense of personal funds of citizens, funds of legal entities and other funds on the basis of contracts, including voluntary medical insurance contracts (hereinafter referred to as the contract);

"consumer" - an individual who intends to receive or receives paid medical services personally in accordance with the contract. A consumer receiving paid medical services is a patient covered by the Federal Law "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation";

"customer" - an individual (legal) person who intends to order (purchase) or order (purchase) paid medical services in accordance with the contract in favor of the consumer;

"executor" - a medical organization providing paid medical services to consumers.

concept "medical organization" used in these Rules in the meaning defined in the Federal Law

3. Paid medical services are provided by medical organizations on the basis of the list of works (services) constituting medical activities and specified in the license for medical activities issued in the prescribed manner.

4. Requirements for paid medical services, including their scope and timing of provision, are determined by agreement of the parties to the contract, unless federal laws, other regulatory legal acts of the Russian Federation provide for other requirements.

5. These Rules are brought to the attention of the consumer (customer) by the contractor in a clear and accessible form.

II. Conditions for the provision of paid medical services

6. When concluding a contract, the consumer (customer) is provided in an accessible form with information on the possibility of obtaining the appropriate types and volumes of medical care without charging a fee under the program of state guarantees of free provision of medical care to citizens and the territorial program of state guarantees of free provision of medical care to citizens (hereinafter - respectively program, territorial program).

The consumer's refusal to conclude a contract cannot be the reason for reducing the types and volumes of medical care provided to such a consumer without charging a fee within the framework of the program and the territorial program.

7. Medical organizations participating in the implementation of the program and the territorial program have the right to provide paid medical services:

a) on other terms than those stipulated by the program, territorial programs and (or) target programs, at the request of the consumer (customer), including but not limited to:

establishment of an individual post of medical observation during treatment in a hospital;

the use of drugs that are not included in the list of vital and essential drugs, if their appointment and use is not due to vital indications or replacement due to individual intolerance to drugs included in the specified list, as well as the use of medical devices, medical nutrition, including the number of specialized health food products that are not provided for by the standards of medical care;

b) when providing medical services anonymously, with the exception of cases provided for by the legislation of the Russian Federation;

c) citizens of foreign states, stateless persons, with the exception of persons insured under compulsory health insurance, and citizens of the Russian Federation who do not permanently reside on its territory and are not insured under compulsory health insurance, unless otherwise provided by international treaties of the Russian Federation;

d) when applying for medical services independently, with the exception of cases and the procedure provided for in Article 21 of the Federal Law "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation", and cases of emergency, including emergency specialized, medical care and medical care provided by in an urgent or emergency manner.

8. The procedure for determining prices (tariffs) for medical services provided by medical organizations that are budgetary and state-owned state (municipal) institutions is established by the bodies exercising the functions and powers of the founders.

Medical organizations of other organizational and legal forms determine prices (tariffs) for paid medical services provided on their own.

9. When providing paid medical services, the procedures for the provision of medical care approved by the Ministry of Health of the Russian Federation must be observed.

10. Paid medical services may be provided in full of the standard of medical care approved by the Ministry of Health of the Russian Federation, or at the request of the consumer in the form of separate consultations or medical interventions, including in an amount exceeding the scope of the performed standard of medical care.

III. Information about the contractor and the medical services provided by him

11. The Contractor is obliged to provide, by posting on the website of a medical organization in the information and telecommunication network "Internet", as well as on information stands (racks) of a medical organization, information containing the following information:

a) for a legal entity - the name and company name (if any);

for an individual entrepreneur - last name, first name and patronymic (if any);

b) the address of the location of the legal entity, the data of the document confirming the fact of entering information about the legal entity in the Unified State Register of Legal Entities, indicating the body that carried out the state registration;

the address of the place of residence and the address of the place of medical activity of an individual entrepreneur, the data of a document confirming the fact of entering information about an individual entrepreneur in the Unified State Register of Individual Entrepreneurs, indicating the body that carried out the state registration;

c) information about the license to carry out medical activities (number and date of registration, list of works (services) constituting the medical activities of a medical organization in accordance with the license, name, location address and telephone number of the licensing authority that issued it);

d) a list of paid medical services indicating prices in rubles, information on the conditions, procedure, form of providing medical services and the procedure for their payment;

e) the procedure and conditions for the provision of medical care in accordance with the program and the territorial program;

f) information on medical workers involved in the provision of paid medical services, on the level of their professional education and qualifications;

g) the mode of operation of a medical organization, the work schedule of medical workers involved in the provision of paid medical services;

h) addresses and phone numbers of the executive authority of the constituent entity of the Russian Federation in the field of protecting the health of citizens, the territorial authority of the Federal Service for Supervision in the Sphere of Health Care and the territorial authority of the Federal Service for Supervision of Consumer Rights Protection and Human Welfare.

12. Information posted on information stands (racks) should be available to an unlimited number of people during the entire working time of a medical organization providing paid medical services. Information stands (racks) are located in an accessible place for visitors and are designed in such a way that you can freely get acquainted with the information posted on them.

13. The contractor provides for review at the request of the consumer and (or) the customer:

a) a copy of the constituent document of a medical organization - a legal entity, the regulation on its branch (department, other territorially separate structural unit) involved in the provision of paid medical services, or a copy of the certificate of state registration of an individual as an individual entrepreneur;

b) a copy of the license to carry out medical activities with a list of works (services) that make up the medical activities of a medical organization in accordance with the license.

14. When concluding a contract, at the request of the consumer and (or) the customer, they must be provided in an accessible form with information on paid medical services containing the following information:

a) the procedures for the provision of medical care and the standards of medical care used in the provision of paid medical services;

b) information about a particular medical worker providing the relevant paid medical service (his professional education and qualifications);

c) information about the methods of providing medical care, the risks associated with them, possible types of medical intervention, their consequences and the expected results of the provision of medical care;

d) other information related to the subject of the contract.

15. Prior to the conclusion of the contract, the contractor shall notify the consumer (customer) in writing that failure to comply with the instructions (recommendations) of the contractor (medical worker providing paid medical services), including the prescribed treatment regimen, may reduce the quality of the provided paid medical service, entail the impossibility of its completion on time or adversely affect the health of the consumer.

IV. The procedure for concluding a contract and paying for medical services

16. The contract is concluded by the consumer (customer) and the contractor in writing.

17. The contract must contain:

a) information about the performer:

name and company name (if any) of a medical organization - a legal entity, location address, data of a document confirming the fact of entering information about a legal entity in the Unified State Register of Legal Entities, indicating the body that carried out the state registration;

surname, name and patronymic (if any) of an individual entrepreneur, address of residence and address of the place of medical activity, data of a document confirming the fact of entering information about an individual entrepreneur in the Unified State Register of Individual Entrepreneurs, indicating the body that carried out the state registration;

the number of the license to carry out medical activities, the date of its registration, indicating the list of works (services) that make up the medical activities of the medical organization in accordance with the license, the name, address of the location and telephone number of the licensing authority that issued it;

b) last name, first name and patronymic (if any), residential address and telephone number of the consumer (legal representative of the consumer);

surname, name and patronymic (if any), address of the place of residence and telephone number of the customer - an individual;

the name and address of the location of the customer - legal entity;

c) a list of paid medical services provided in accordance with the contract;

d) the cost of paid medical services, the terms and procedure for their payment;

e) conditions and terms for the provision of paid medical services;

f) position, surname, name, patronymic (if any) of the person concluding the contract on behalf of the contractor, and his signature, surname, name, patronymic (if any) of the consumer (customer) and his signature. If the customer is a legal entity, the position of the person concluding the contract on behalf of the customer is indicated;

g) the responsibility of the parties for failure to comply with the terms of the contract;

h) the procedure for changing and terminating the contract;

i) other conditions determined by agreement of the parties.

18. The contract is drawn up in 3 copies, one of which is with the contractor, the second - with the customer, the third - with the consumer. If the contract is concluded by the consumer and the contractor, it is drawn up in 2 copies.

19. An estimate may be drawn up for the provision of paid medical services. Its preparation at the request of the consumer (customer) or contractor is mandatory, while it is an integral part of the contract.

20. If the provision of paid medical services requires the provision of additional medical services on a reimbursable basis that are not provided for by the contract, the contractor is obliged to notify the consumer (customer) about this.

Without the consent of the consumer (customer), the contractor is not entitled to provide additional medical services on a reimbursable basis.

21. If the provision of paid medical services requires the provision of additional medical services for emergency reasons to eliminate the threat to the life of the consumer in case of sudden acute diseases, conditions, exacerbations of chronic diseases, such medical services are provided free of charge in accordance with the Federal Law "On the Fundamentals of Protection health of citizens in the Russian Federation".

22. If the consumer refuses to receive medical services after the conclusion of the contract, the contract is terminated. The contractor informs the consumer (customer) about the termination of the contract at the initiative of the consumer, while the consumer (customer) pays the contractor the costs actually incurred by the contractor related to the performance of obligations under the contract.

23. The consumer (customer) is obliged to pay for the medical service provided by the contractor on time and in the manner specified by the contract.

24. In accordance with the legislation of the Russian Federation, the consumer (customer) is issued a document confirming the payment for the provided medical services (cash receipt, receipt or other form of strict accountability (document of the established form)).

25. After the execution of the contract, the Contractor shall issue to the consumer (legal representative of the consumer) medical documents (copies of medical documents, extracts from medical documents) reflecting the state of his health after receiving paid medical services.

26. The conclusion of a contract for voluntary medical insurance and payment for medical services provided in accordance with the said contract shall be carried out in accordance with the Civil Code of the Russian Federation and the Law of the Russian Federation "On the organization of insurance business in the Russian Federation".

V. Procedure for the provision of paid medical services

27. The contractor provides paid medical services, the quality of which must comply with the terms of the contract, and in the absence of conditions on their quality in the contract, the requirements for services of the corresponding type.

If the federal law, other regulatory legal acts of the Russian Federation provide for mandatory requirements for the quality of medical services, the quality of paid medical services provided must comply with these requirements.

28. Paid medical services are provided subject to the informed voluntary consent of the consumer (legal representative of the consumer), given in the manner prescribed by the legislation of the Russian Federation on the protection of the health of citizens.

29. The contractor provides the consumer (legal representative of the consumer) at his request and in a form accessible to him information:

about the state of his health, including information about the results of the examination, diagnosis, treatment methods, the risks associated with them, possible options and consequences of medical intervention, expected results of treatment;

about medicines and medical devices used in the provision of paid medical services, including their expiration dates (warranty periods), indications (contraindications) for use.

30. When providing paid medical services, the Contractor is obliged to comply with the requirements established by the legislation of the Russian Federation for the preparation and maintenance of medical records and accounting and reporting statistical forms, the procedure and deadlines for their submission.

VI. Responsibility of the contractor and control over the provision of paid medical services

31. For non-fulfillment or improper fulfillment of obligations under the contract, the performer shall be liable under the legislation of the Russian Federation.

32. Harm caused to the life or health of the patient as a result of the provision of low-quality paid medical services is subject to compensation by the contractor in accordance with the legislation of the Russian Federation.

33. Compliance with these Rules is monitored by the Federal Service for Supervision of Consumer Rights Protection and Human Welfare within the established powers.

In a budgetary institution, diagnostic services, new treatment technologies, dental services, enhanced comfort conditions, and services of doctors belonging to the school of so-called traditional medicine are gradually becoming paid services. For health facilities, commercial activity should not be the goal, but it is allowed and permitted. At the same time, if income is received from such activities, then they and the property acquired at their expense go to the independent disposal of the institution. Rules for the provision of paid medical services: a certificate and license for the chosen type of activity is required. Usually, a medical organization provides patients with a whole range of medical services. In this case, each type of medical activity must be indicated separately in the license. The license is issued for a period of at least 3 years. You need permission from the relevant health authority to conduct paid medical activities. When issuing a permit to a medical institution, the superior governing body of the WA can make an informed decision to limit both the volume and specific types of medical services on a paid basis. Prices for paid services are regulated by the authorities based on the rights of the owner. Moreover, the laws of the Russian Federation do not provide for mandatory coordination of prices (prices are set in accordance with the legislation of the Russian Federation), i.e. This is not an obligation, but an opportunity for the authorities. But if local governments issue a decree on the application of tariffs for medical services, then it is mandatory for execution. If there is no order, then the prices are calculated based on the economic interests of the organization. Payment for medical services can be made both in banks and in the institutions themselves. The consumer must have either a cash receipt or a copy of the payment form. The organization must provide free and reliable information on prices and display the liver of paid medical services indicating the cost, as well as information on the qualifications and certification of specialists. The consumer has the right to demand a reduction in the cost of the provided service of inadequate quality, terminate the contract and demand compensation for losses. Compensation for harm (damage) consists in the payment of a sum of money that he has the right to receive to restore his impaired health in connection with the provision of poor medical care to him, as well as compensation for lost profits and moral damage. The amount of such compensation depends on the amount of expenses spent on the treatment of the victim, the result of treatment (recovery, chronicity of the process or injury, disability, death). The patient has the right to information about alternative methods of treatment, to refuse treatment, to respect the confidentiality of medical information. However, the doctor and the patient will only find mutual understanding when the patient realizes the economic need to maintain health, his own responsibility to society for the results of treatment.

27. Forms of remuneration in the health care of the Russian Federation

Forms of remuneration. The tariff rate is the absolute amount of remuneration of labor of various categories of workers per unit of time, expressed in monetary terms. The tariff rates for wages for public sector employees are fixed in the Unified Tariff Schedule approved by the Government of the Russian Federation, which forms the basis of the tariff wage system (a time-based system based on uniform tariffs).

The tariff scale is a set of tariff rates (monthly salaries) and tariff coefficients divided by categories of wages and tariff coefficients representing the ratio of the tariff rate of this category to the rate of the first category.

The size of the tariff coefficients of the tariff scale is relatively stable, while the tariff rates are constantly changing. Typically, such a change occurs in the direction of raising rates in order to index income, that is, to take into account the inflation factor in income, which causes a decrease in real income due to an increase in prices for consumer goods and services.

The main forms of remuneration are:

Time:

simple time,

time-bonus;

Piecework:

straight piecework,

piecework premium,

piecework progressive,

indirect piecework;

Chord.

At time-based forms payment is made for a certain amount of time worked, regardless of the amount of work performed. The time-based form of remuneration is most common in health care; it holds a leading position in the public sector, financed from federal, regional and local budgets and compulsory medical insurance funds.

piecework form remuneration is based on the establishment of wages "depending on the volume (quantity) of work performed, services rendered for a certain period of time (most often - for a month).

The advantage of the piecework form of wages is that the amount of wages is directly related to the amount of labor expended, measured in terms of the amount of work performed.

However, in health care it is extremely difficult to measure the volume of work performed, services in kind. In addition, if the work performed is of a group, collective nature, you either have to allocate a share of the volume of work or services performed by each employee, or calculate piecework wages based on the entire team, and then divide it among the members of the team in accordance with the measure of their participation. in labor, determined by the so-called labor participation rate (KTU).

Piecework premium the system provides for an increase in prices or the entire amount of wages for high quality work, economical use of materials and energy, the use of progressive labor methods, careful attitude to equipment, and the provision of additional services. But along with bonuses, a de-bonding mechanism can be applied in the form of fines for violating the rules, poor quality of care, and causing material damage.

At piece-progressive payment rates are increased in accordance with the overfulfillment of production standards without reducing the quality of services.

The central problem of using the piecework form of remuneration is the determination of prices for single works and services.

By applying the Piece-rate payment system to the auxiliary medical personnel serving the main process carried out by doctors, it is used , indirect piecework payment of support staff to stimulate the work of nurses and other workers. In such a system, the remuneration of support staff is made dependent on the volume of medical services provided by the doctors served by the support staff.

chord the system is based on an increase in prices or the total amount of wages, if the work, services are performed in an accelerated manner at non-working hours or at a reduced time compared to the standard. When using the chord system, wages are usually set not for the performance of individual manipulations or services, but for the performance of the entire work as a whole and are not necessarily timed to monthly payments.

As the health care system enters market relations, it is advisable to switch to a mixed form of wages, combining the features and properties of a time-based and piecework system.

"Budget healthcare institutions: accounting and taxation", 2008, N 10

In the article, the author, considering the regulations (federal, subjects of the Russian Federation), highlights the procedure for organizing income-generating activities in healthcare institutions financed from different budgets of the budgetary system of the Russian Federation, and gives answers to frequently asked questions by accountants on this topic.

General provisions on the procedure for providing paid medical services are regulated by the Rules approved by Decree of the Government of the Russian Federation of 13.01.1996 N 27 (hereinafter referred to as the Rules). This document extends its legal force to medical institutions, regardless of their form of ownership, including medical and preventive, research institutes and state medical educational institutions of higher professional education. The information contained in this document is of a general nature, and many aspects regarding the procedure for providing paid services are not covered in them. for example, according to clause 9 of this document, the prices for medical services provided to the population for a fee are established in accordance with the legislation of the Russian Federation. At the same time, it does not say whether market conditions, the quality and consumer properties of services, the degree of urgency of ordering (with the exception of emergency medical care) should be taken into account, nor does it follow from this document whether medical institutions have the right to establish benefits for certain categories of citizens.

To regulate the procedure for the provision of paid services by state medical institutions of a constituent entity of the Russian Federation, the authorities of the constituent entities of the Russian Federation develop more detailed and detailed regulations. In particular, for medical institutions receiving full or partial funding from the budget of the city of Moscow, the Order of the Ministry of Health of the Moscow Region dated April 23, 2008 N 204 "On Approval of the Procedure for the Provision of Paid Medical Services by State and Municipal Healthcare Institutions of the Moscow Region" was developed (hereinafter referred to as the Procedure for Providing paid services in the Moscow Region), from the budget of St. Petersburg - Order of the Committee for Health of the Government of St. Petersburg dated 04.04.2005 N 112-r "On the procedure for providing paid medical services" (hereinafter - the Procedure for providing paid services in the joint venture); and medical institutions of the Udmurt region apply the Rules for the provision of paid services in the MA, approved by Order of the Ministry of Health of the Udmurt Republic of November 13, 2006 N 485.

Despite the fact that the above regulations were developed and approved by the executive authorities of different subjects of the Russian Federation and in different time periods, the information contained in them is very similar. Based on these and other similar documents, one can find answers, if not to all the questions asked by accountants regarding the provision of paid medical services, then at least to some of them.

What medical services can be provided by health care institutions on a paid basis and what documents are drawn up in connection with this? Medical services are provided to the population on a paid basis, subject to the following conditions:

The institution has a permit for the provision of paid medical services issued by a commission located at the Ministry of Health of the corresponding subject of the Russian Federation.
Inclusion of a medical service in the List of paid medical services developed and approved by the Ministry of Health of the relevant subject of the Russian Federation (in certain subjects of the Russian Federation, for example, in the Udmurt region, the list of medical services that can be provided for a fee is not approved by a separate document, but is included in the Rules for the provision of paid medical services operating in the territory of this subject).
The absence of the name of the medical service in the list of services performed by the institution as part of the implementation of the program of state guarantees for the provision of free medical care to citizens of the Russian Federation, including the regional program of compulsory medical insurance.
The desire of the patient to receive a medical service for a fee, even if it can be provided to him free of charge, as it is included in the list of types of medical care provided for by the State Guarantees Program.
The patient is a citizen of a foreign state who is not subject to compulsory health insurance in the territory of the Russian Federation.
Availability of a personal account for recording funds from income-generating activities in the territorial bodies of the Federal Treasury.

As for the documentation of the paid medical services provided, for this purpose, orders must be issued in the institution stating:

head of the department or office for the provision of paid medical services (if any);
rules for the provision of paid medical services;
regulation on remuneration of employees engaged in the provision of paid medical services;
schedules (schedules) for the provision of services by specialists;
a list of employees providing paid medical services during regular working hours.

In addition, according to certain regulations of the constituent entities of the Russian Federation, in particular clause 2.2 of the Rules for the provision of paid services in the MA, the institution must have an order from the head who approved the list of medical equipment (purchased both at the expense of income-generating activities and at the expense of budgetary allocations ) used in the course of providing paid medical services to the population. Other normative acts studied by the author do not contain such a requirement. Accountants often ask: is it possible to use equipment purchased at the expense of budgetary appropriations or compulsory medical insurance funds when providing paid services? In the absence of an act of the subject of the Russian Federation prohibiting the use of the mentioned equipment in the provision of paid services, according to the author, there are no obstacles to this.

In addition to the above documents, for the provision of paid medical services, a contract for the provision of paid services is concluded with the person receiving them. It indicates the type of medical service provided or expensive treatment, the number and duration of the license, the cost of work performed under the contract. In addition, it must contain information that the patient is notified of the opportunity to receive this service free of charge (if this medical service can be provided to him as part of the implementation of the free medical care program).

What are the features of organizing work and planning the remuneration of medical personnel in the provision of paid medical services? All regulations of the constituent entities of the Russian Federation contain a requirement for separate accounting of the working hours of specialists providing paid medical services.

At the same time, the requirement for the distribution of funds received from the provision of paid medical services is contained only in the Procedure for the provision of paid services in the Moscow Region. According to clause 3.6 of this document, 60% of the indicated income is used to pay for the work of medical personnel who provided outpatient care (including accruals), and 55% for those who provided inpatient care. At the same time, no more than 10% of income from paid services is directed to the remuneration of the administrative and managerial personnel of the institution.

As for the material incentives for the head of the institution for organizing work on the provision of paid medical services, its amount must be agreed with the relevant governing body (clause 3.7 of the Procedure for the provision of paid services in the Moscow Region).

Thus, if the legislation of a constituent entity of the Russian Federation establishes percentages for the distribution of funds received from the provision of paid services directed to the remuneration of persons involved in the implementation of this activity, then the institution must take this requirement into account when developing an internal regulation on remuneration.

Regarding the organization of the work of medical personnel within the framework of income-generating activities, we note that almost all regulatory acts of the constituent entities of the Russian Federation require medical personnel to provide paid services in their free time from their main work. In this regard, separate work schedules should be drawn up, that is, at the basic rate and for the provision of paid services. However, in exceptional cases, subject to the priority provision of free medical care to citizens, the provision of paid medical services is allowed during the main working hours (for example, in connection with the technology of conducting). The hours of work of medical personnel providing paid services during their main work are reflected in the time sheet for income-generating activities. The Ministry of Health of some constituent entities of the Russian Federation, taking into account the fact that it is usually extremely difficult for medical staff to provide medical services outside of working hours, allows them to be provided during regular working hours. At the same time, it is stipulated that this should not create obstacles for receiving free medical care to persons entitled to it (clause 3.6 of the Procedure for the provision of paid services in the joint venture) or the priority of providing citizens with free medical care in accordance with the state program (clause 3.4) Rules for the provision of paid services in the MA).

At the same time, it should be borne in mind that the provision of additional services during regular working hours, including paid ones, by increasing the intensity or productivity of labor, entails a decrease in the quality of medical care. In fact, as a rule, medical workers provide paid services during their main work hours. At the same time, patients who receive medical services for a fee are served first, and then under the state medical assistance program. Thus, the current legislation of the subject of the Russian Federation is violated.

How is the cost of paid medical services formed and approved by whom? In individual subjects (Moscow Region, St. Petersburg), prices for paid medical services provided by institutions are calculated on the basis of methodological recommendations developed for these purposes by the executive bodies of the constituent entity of the Russian Federation (clause 5.1 of the Procedure for the provision of paid services in the Moscow Region, clause 6.1 Rules for the provision of paid services in the MA). In other constituent entities of the Russian Federation, prices for medical services are formed taking into account methodological recommendations for the formation and application of free prices and tariffs for products, goods, services, based on the calculation (clauses 7.1, 7.3 of the Procedure for the provision of paid services in the joint venture).

Price lists for paid services provided by state healthcare institutions are approved by the heads of institutions and agreed with the Ministry of Health of the relevant subject of the Russian Federation. As for price lists for paid services provided by municipal institutions, they are established by local governments of municipalities in accordance with Federal Law No. 131-FZ of October 6, 2003 "On the General Principles of Organizing Local Self-Government in the Russian Federation" (clause 5.3 services in MO).

What forms of statistical reporting must an institution provide when providing paid services? Institutions submit statistical reports in the following forms: N P-1 "Information on the production and shipment of goods and services" (monthly), N 1-service "Information on the volume of paid services to the population" (once a year)<1>. The figures reflected in these forms are given in actual current prices, including value added tax.

<1>The forms and the procedure for filling them out were approved by Rosstat Resolution No. 61 of October 27, 2006 "On Approval of the Procedure for Reflecting Information on the Volume of Paid Services to the Population in the Forms of Federal State Statistical Observation."

Accounting for income and expenses from the provision of paid medical services

Institutions financed from the budgets of all levels, state off-budget funds allocated according to the budget estimate, or receiving income from paid medical services provided to citizens under the territorial program of compulsory medical insurance, as well as receiving income from other sources, for tax purposes are required to maintain separate accounting of income (expenses) received (produced) within the framework of targeted financing and from other sources (clause 6.1 of the Procedure for the provision of paid services in the Moscow Region).

The accounting policy of the institution should reflect:

the procedure for the distribution of indirect costs;
method for determining the proceeds from the sale of products, works, services;
method of estimating inventories;
the moment of determining the tax base for the sale (transfer) of goods, works, services subject to value added tax.

Funds received from income-generating activities are spent by institutions in accordance with the estimates of income and expenses approved in the manner prescribed by the main manager. In the event that income is received in an amount greater than that reflected in the estimate, it should be amended.

Accounting for the provision of paid medical services is carried out in accordance with the requirements of Instruction N 25n<2>which involve accounting on an accrual basis. With this method, income is recognized at the time of the sale of goods, works, services, and expenses - at the moment when they are incurred.

<2>Instructions for budget accounting, approved. Order of the Ministry of Finance of Russia dated February 10, 2006 N 25n.

Correspondence of accounts to reflect the accrual of income from income-generating activities will be as follows:

			Instructions
Accrued income from the provision medical service
Money received in account payment for the rendered service
The actual cost is formed service rendered
Written off actual cost expenses incurred
Accrued income tax
Money debited from account to pay for expenses incurred in income generating activities: to the cash desk of the institution (for settlements through accountable persons); with non-cash payments

If, according to the legislative acts of a constituent entity of the Russian Federation, funds from consumers of paid services are credited directly to the personal account of the financial body of the corresponding subject, then the accrual of income from income-generating activities should be documented in the following accounting entries:

Accounting for the costs incurred in the provision of paid services. In accordance with paragraph 73 of Instruction N 25n, operations to form the actual cost of paid services are reflected in the debit of account 2 106 04 340 "Increase in the cost of manufacturing materials, finished products (works, services)" in correspondence with the credit of the corresponding accounts of analytical accounting:

2 302 00 730 "Increase in accounts payable for settlements with suppliers and contractors";
2 104 00 410 "Decrease in the cost of depreciable fixed assets";
2 303 02 730 "Increase in accounts payable for the unified social tax and insurance premiums for compulsory pension insurance in the Russian Federation";
2 303 06 730 "Increase in accounts payable under compulsory social insurance against accidents at work and occupational diseases";
2 105 00 4400 "Decrease in the value of inventories".

The write-off of expenses incurred for the services rendered is carried out by accounting entries (clause 217 of Instruction N 25n):

Debit of account 2 401 01 130 "Income from market sales of finished products, works, services"

Credit of account 2 106 04 440 "Reducing the cost of manufacturing materials, finished products (works, services)".

The report on financial results of activities (f. 0503121) within the framework of income-generating activities is formed from the credit of account 2 106 04 440 "Reducing the cost of manufacturing materials, finished products (works, services)" taking into account the analytics of costs by their types, that is, by KOSGU codes<3>.

<3>The classifier of operations of the public administration sector, approved. Order of the Ministry of Finance of Russia dated August 24, 2007 N 74n.

When accounting for costs incurred as part of an income-generating activity, the difficulty is caused by the procedure for reflecting in the budget accounting of costs that, at the time they are made, cannot be attributed to a specific source of funding. The need to allocate costs in accordance with the source of their financing is dictated by:

linking all the costs of budgetary institutions to the sources of their financing;
the requirement of Art. 321.1 of the Tax Code of the Russian Federation to distribute the costs of paying for utilities, communication services, transportation costs for servicing administrative and managerial personnel, expenses for all types of repairs of fixed assets for the purpose of taxing the profits of a budgetary institution.

Methods of cost distribution in the above-mentioned Procedures for the provision of paid medical services are not established. As mentioned above, institutions should establish them themselves and reflect in the accounting policy.

T.Silvestrova

Deputy magazine editor-in-chief

"Budget Organizations:

accounting and taxation"