Reimbursement penalties. Doctors demand change in regulations

The conversation focused on legal issues concerning a case that has been pending for more than a year, which significantly strikes at the welfare of the youngest patients and the doctors who treat them. The Patient Ombudsman has undertaken a thorough assessment of the problem, and the talks will continue in the coming weeks.

- It is a priority for us to look for a solution that will allow fair treatment of doctors who, in good faith and in accordance with current medical knowledge, wrote prescriptions for this preparation to their patients. The situation that has arisen negatively affects the work of doctors, raises fears of making difficult decisions and reduces trust in official mechanisms. We hope to reach a consensus soon, which is why we are with the Patient Ombudsman today and present this problem from our perspective," stressed Klaudiusz Komor, vice president of the NRL.

• Since the beginning of 2023, the NIL has been approached by doctors who have been summoned from various parts of Poland by the NFZ to reimburse their prescriptions for the products in question. The Supreme Chamber of Physicians organized meetings of wrongly penalized physicians with representatives of the NFZ and the Ministry of Health, during which the physicians argued the legitimacy of their decisions and raised the issue of unclearly drafted regulations on the reimbursement eligibility of the mentioned products.
• Thanks to the NIL's support, doctors fined by the NFZ during a debate in the Senate of the Republic of Poland presented key demands advocating, among other things, a substantive reassessment of medical recommendations for continuing treatment of allergic children with milk replacer, not covered by reimbursement indications; the way in which the NFZ conducts inspections; or a complete exemption of doctors from the obligation to indicate the scope of reimbursement for drugs and special medical purposes.
• The Ministry of Health set up a team whose task was to gather international experience in applications supporting the work of a doctor in the matter of drug reimbursement, to identify a list of drugs entering the automatic system for determining reimbursement, to develop the principles of operation of the created IT system and an artificial intelligence model that will support the selection of reimbursement levels. Vice President of the Supreme Medical Council Klaudiusz Komor participated in the work of the said team.
• Thanks to the initiatives taken by the NIL, the topic of punished doctors for helping the youngest patients has also become high-profile in the media, allowing to sensitize the public to a problem that patients are not aware of on a daily basis.
• In order to defend wrongly penalized physicians, an analysis of legal actions that individual physicians can take to challenge the NFZ's imposition of penalties for prescribing a reimbursable product outside of reimbursement indications has been prepared on behalf of NIL. NIL provides sample pleadings to physicians who wish to assert their rights and defend themselves against unfairly imposed penalties.

Efforts to abolish the obligation for physicians to determine reimbursement levels will continue to be one of the priorities of the upcoming activities of the Medical Council.

Source: NIL