What to do if the clinic refuses to refer you for treatment

Recently, patients have increasingly complained that they are denied referrals at public clinics or hospitals. This applies to both research referrals and hospitalization referrals. Despite the fact that the CHI policy is legally valid throughout the country, people are often told that they can only be served at their place of residence. Is it legal? What to do if you are refused a referral? Experts say.

One of the most common questions from patients: is it true that medical care can only be obtained by referral for treatment or diagnosis? And should it always be issued in the form 057u-04? Let’s try to figure it out with the help of experts in the field of compulsory medical insurance.

Indeed, a referral in the form 057u-04 is required if you need planned hospitalization, diagnostics, rehabilitation, or consultation with a narrow specialist. If you do not have such a document, you will not be able to receive the listed assistance under the CHI policy. The document is officially called “Referral for hospitalization, rehabilitation treatment, examination, consultation.”

But! To get the so-called. primary medical care (it is provided in polyclinics by therapists, pediatricians and general practitioners) no referral is needed! And the patient can come to them without any papers.

However, if specialized medical care is required, which is provided by specialist doctors in the same clinic, alas, you will have to receive a referral from the same pediatricians, therapists and general practitioners. Only then can you independently make an appointment with the right specialist – a cardiologist, an allergist, a neurologist, an endocrinologist, etc.

Referrals are also needed to obtain laboratory or instrumental examinations in the clinic (they are issued by the same general practitioner or specialist).

But what if you need a study that is simply not done in the clinic, because they require medical supervision? For example, examinations under general anesthesia, endoscopic and laparoscopic procedures. In this case, the doctor of the polyclinic must issue a referral for hospitalization in a hospital.

If there are no indications for an inpatient examination, and the clinic is either missing or the necessary equipment is broken, the doctor must refer the patient to another medical organization.

To receive specialized inpatient medical care at your place of residence (in the region of registration), you also need a referral, except for emergency or urgent situations when no referral is needed. Referral for hospitalization, rehabilitation treatment, examination, consultation is issued by any (!) doctor of the clinic to which the patient is assigned. According to such a document, you are entitled to such “buns” as a comprehensive examination using modern methods and equipment, treatment in a hospital (including day care), consultations of specialists.

According to the law, we can choose any medical organization for hospitalization if it works under the CHI program in the region. But in practice, you will be sent to where there are free beds, which is not against the law. And yet, if the patient insists that he wants, for example, to be operated on in another place, theoretically the problem can be solved. “In this case, you need to contact the medical insurance organization that issued the CHI policy. True, then you will have to wait, including being prepared for the fact that the waiting time for planned hospitalization in the hospital chosen by the patient, if it is fully loaded, may exceed the 30 days established by law, which he will be informed about, ”emphasizes the deputy head of the working group of the All-Russian Union insurers for the organization of CHI Elena Tretyakova.

By the way, if there is no hospital in the region where they can provide the necessary assistance in your profile, you must be sent to another region.

However, it will be more difficult to receive treatment in federal centers – from January 1, 2021, a new procedure came into force, according to which it is possible to receive a referral there only if there are certain indications. For example, with an atypical course of the disease or the absence of the effect of the therapy; in the complete absence of the necessary treatment methods in regional clinics, a high risk of complications, etc. If there are indications, they do not have the right to refuse you. Then the referral to the federal center must be issued to you by the attending physician at the place of residence.

A curious fact: the law gives the patient the right to apply to the federal medical center with a request for hospitalization directly. “If there are results of laboratory, instrumental and other types of studies confirming the established diagnosis, the patient can independently apply to the FMO for medical assistance. In this case, a referral is not required, but a positive decision of the FMO regarding hospitalization is needed, ”says Mikhail Pushkov, an expert from an insurance medical organization (CMO).

So, in any case, it is important to know: if you have a referral, you are required to provide medical assistance on it. What if they refuse to give it to you? According to the law, the only reason for refusing to issue a referral can be the lack of sufficient evidence for hospitalization or the lack of necessary documents. But life makes its own adjustments, and very often patients are denied from scratch. In this case, you need to write a complaint to the head physician of the medical organization that refused you and (or) complain to the CMO – its representatives must take measures, up to a fine for a polyclinic or hospital for an unlawful refusal to issue a referral.