The Federal Compulsory Medical Insurance Fund proposed 12 criteria for monitoring the quality of work of the insurance medical organization

The draft order on the start of monitoring the work of the insurance companies has been published on the federal portal of draft regulations for public discussion. According to the document, the TFOMS will collect several types of statistical information from the insurance companies on a quarterly basis, calculate the efficiency of the insurers and send the information to the FFOMS to form the final rating.

There are 12 indicators in the list, including, for example, maintaining personalized records of information on insured persons and personalized records of attachment of insured persons. The share of insured persons who have outdated data in the register of insured persons (insurers are responsible for the relevance of this information) or who have not selected an outpatient medical organization for service will be monitored according to these points. The latter also applies to patients who came for treatment to another entity.

A number of points concern informing patients – consulting on the possibility of receiving treatment outside the region, in federal clinics, on the need to undergo examinations under dispensary supervision and the possibility of undergoing preventive examinations. It will also be checked how HMOs protect the rights of patients who have disagreements with medical organizations.

Individual analytical indicators include compliance with the volumes of funding for clinics and the absence of excess volumes, the share of fines that clinics paid during the financial year, and the share of substantiated (not appealed) assessments of the quality of medical care in cases of payment for medical care under compulsory medical insurance.

The norm on special monitoring of SMOs appeared in 552-FZ, which was adopted in December 2024. The idea of ​​introducing special monitoring of SMOs has been discussed since 2020, but was reflected in No. 326-FZ only now.

In parallel, another order of the Ministry of Health of the Russian Federation is in effect - No. 255n of March 26, 2021 "On approval of the procedure for the implementation of TFOMS control over the activities of health insurance organizations", which also describes which aspects of the work of the HMO, although of a more general nature, require special attention from auditors. This order was updated in 2021, it clarified that inspections can be both remote (documentary) and on-site.

The idea of ​​strengthening control over insurance companies or liquidating such organizations has been periodically discussed in the industry over the past few years. On the other hand, insurers themselves often state the need to expand their functionality and more closely connect them to the system of distributing compulsory medical insurance volumes or conducting control measures.

In early 2025, the State Duma received a bill from the New People party on depriving insurers in the compulsory medical insurance sector of part of the income they receive from imposing sanctions on clinics. As parliamentarians believed, the insurance companies are interested in conducting more and more inspections, pursuing the goal of obtaining additional income. The project was expectedly criticized by the All-Russian Union of Insurers, but also did not receive the approval of the Government and the Ministry of Health of the Russian Federation.

In 2024, according to the Federal Compulsory Medical Insurance Fund, 23 medical insurance organizations operated in the field of compulsory medical insurance. The majority of individuals (132.2 million people, or 90.5%) were insured in nine medical insurance organizations and their branches, 30% in SOGAZ-Med. RUB 26.7 billion was spent on supporting the work of the medical insurance organizations in 2023 (more recent information was not provided) - this includes both the standard for conducting business and funds received by insurance organizations from sanctions against clinics.