Arbitration as dispute resolution in primary outpatient care – potential and reality

General Medicine, 2023, 25(2), 3-11.

M. Dzhuglarska, T. Zlatanova, N. Popov, Ts. Petrova-Gotova, R. Yaneva,D. Shtereva-Tzоuni, E. Naseva, M. Lazarova

Faculty of Public Health „Prof. Tsekomir Vodenicharov, MD, DSc“, Medical University ‒ Sofia

Abstract. The control over the execution of primary outpatient care (POC) provider contracts frequently ends with a report of discovered violations. Those violations concern the payment for provided medical services and cause disputes between two parties – the National Health Insurance Fund (NHIF), in its role as the control body, and the general practitioner (GP) in his role as the inspected POC provider. In this aspect, the goal of this research is to study the potential and realities of using arbitration in dispute resolution in POC with NHIF. The research is complex. It encompasses the existing legal framework, the public annual reports of NHIF’s activity and the results from a questionnaire survey conducted in the period between June and October 2022 among GPs from all over Bulgaria who are NHIF’s contractual partners. The summarized results show securing of the right to protection of the inspected medical care providers, incl. POC providers, by including an arbitration commission in the NHIF’s penalty enforcement process. Arbitration is a mandatory element of penalty proceedings when objections are filed in regard to the discovered violations but only in case of a lawfully formed arbitration commission and only for a specific case. Meanwhile, the principle of parity, which is applied in forming the commission board hides a risk that no agreement is reached. In this regard, there are prerequisites for poor functioning of the arbitration, and this is proven by the results of the questionnaire survey. Out of the 394 GPs participating in the survey, almost a third underwent NHIF inspections during the COVID-19 pandemic. Despite the great percentage (90.1%) of handed out reports of discovered violations, objections were filed for an insignificant portion of them (11.9%). The result of the dispute resolution is also indicative – in the majority of disputes (64.3%) arbitration was not applied in the penalty proceedings, and in the rest (35.7%) the disputes considered ended up in 1:2:2 ratio in favor of rejecting the findings and not reaching an agreement due to an even number of votes by the commission members. The GP’s low activity in filing objections also explains the high number of imposed penalties.

Key words: arbitration, control, disputed findings, POC providers

Address for correspondence: Miroslava Dzhuglarska, e-mail: m.djuglarska@foz.mu-sofia.bg