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And what to do if you are denied medical assistance or require money.
SOGAZ-Med recommends that St. Petersburg residents apply to a medical insurance company to resolve disputes when receiving medical assistance under compulsory medical insurance, whether it is exceeding the waiting time for the service, dissatisfaction with the quality of treatment, or even refusal to provide medical care by the medical organization.
We all know one of the basic constitutional provisions: “Everyone has the right to health care and medical assistance.” Today, health insurance organizations play an increasing role in the exercise of this right. Galina Valerievna Razbitskova, director of the St. Petersburg branch of the SOGAZ-Med insurance company, will tell you how the principle of the basic law of the Russian Federation is implemented.
– Not all patients are satisfied with the availability of medical care and the conditions for its provision. Sometimes it is not easy to understand health issues, but there are assistants for this – medical insurance organizations. We not only issue compulsory medical insurance policies, but also protect the rights of patients to receive quality medical care in a timely manner.
For example, the waiting period for an appointment with a district general practitioner should not exceed 24 hours from the moment of contact, a specialist doctor – 14 calendar days. Laboratory and most instrumental studies should be carried out within two weeks. For complex diagnostic methods such as computed tomography (CT) and magnetic resonance imaging (MRI), as well as for planned hospitalization, the waiting period should not exceed 30 calendar days.
– Everybody comes to us like this. For example, relatives of our 80-year-old insured person contacted us for medical assistance. The man needed to undergo a hip replacement surgery. The medical organization, where he applied, was offered to stand in line and undergo surgical treatment in 2 years or pay 300 thousand rubles. Employees of the service for the protection of the rights of the insured “SOGAZ-Med” in a short time organized the treatment of the patient at the expense of the compulsory medical insurance funds. A month later, he was operated on for free and discharged home.
– These are specialists of the insurance company who have the necessary knowledge in the field of legislation to protect the rights of the insured. They interact effectively with patients and help with any difficulties.
Insurance representatives of the 1st level are specialists of the contact center of an insurance medical organization who provide reference and consulting information on standard issues.
Insurance representatives of the 2nd level are specialists who understand the problem locally, accompanying insured citizens when providing them with medical assistance.
– Their activity differs significantly from the work of insurance representatives of the 1st and 2nd levels. These are employees who have undergone special training – experts in the quality of medical care who accompany the insured at all stages of medical care. They take part in the prompt resolution of disputable situations that arise directly at the time of providing medical care to the insured. If necessary, insurance representatives of the 3rd level conduct an examination of the quality of treatment and determine whether the patient’s rights have been violated or not. They play an essential role in the process of protecting the rights of insured citizens.
– This is work with written requests from insured citizens; analysis of the timeliness of dispensary observation, planned hospitalizations and other recommendations based on the results of medical examination; examination of the provision of medical care; participation in the prompt resolution of controversial situations arising at the time of hospitalization. Specialists conduct individual consultations of citizens in order to prevent deterioration of their health and form adherence to treatment.
The main goal of the activities of insurance representatives of the 3rd level is to help and advise the insured in the most difficult moments that require qualified intervention and constant support. It is this method that is the basis for the implementation of a patient-centered approach in work.
– It is too early to give any estimates, but it is worth noting that the total number of insurance representatives of the 3rd level in SOGAZ-Med at the beginning of February 2018 already amounted to more than 300 people. And the number of requests in January 2018 alone was more than 1,8 thousand. We are monitoring the dynamics of requests and today we note that their number is only increasing.
– Some patients, unfortunately, are faced with the formal attitude of one or another doctor. One of the tasks of insurance representatives of the 3rd level is to create a positive experience and further motivation of citizens to undergo treatment. Thus, the insurance representative plays a rather supportive role in the course of treatment.
– The rights of the insured are violated if the patient is required money for the provision of medical care, within the framework of the CHI program; the patient is offered to purchase medications prescribed by a doctor during treatment in a XNUMX-hour hospital or day hospital; the conditions for the provision of medical care are violated, including the waiting times for medical care provided in a planned manner; the patient is denied medical assistance under the compulsory medical insurance.
It’s important to remember. If you are SOGAZ-Med insured and you have any questions regarding the quality of medical care, you can contact the 8-hour SOGAZ-Med contact center by phone 800-100-07-02-XNUMX (free within Russia). You can also get advice in the online chat, on the website or by visiting one of the SOGAZ-Med offices.
Information about the company:
The SOGAZ-Med group of companies has been operating since 1998. The number of insured is over 19 million people. Regional network – more than 600 subdivisions in 40 constituent entities of the Russian Federation. SOGAZ-Med carries out compulsory medical insurance activities: it controls the quality of services provided to the insured when receiving medical care in the compulsory medical insurance system, protects the rights of insured citizens, and restores violated rights of citizens in the pre-trial and judicial order. The Expert RA agency has confirmed the rating of SOGAZ-Med at the A ++ level, which indicates an exceptionally high level of reliability and quality of the company’s services.