Control of Medical Care within the System of Mandatory Health Insurance in Bulgaria

Abstract

The aim of the study was to analyze the regulatory framework and the practice of control activities within the system of mandatory health insurance in Bulgaria, carried out by the National Health Insurance Fund (NHIF) and the Regional Health Insurance Funds (RHIFs), with a focus on the mechanisms for controlling medical care and the expenditure of public funds. Methods: A documentary and regulatory analysis was conducted, covering the current legislation, secondary regulatory acts, the National Framework Contract, the NHIF Budget Act, and official strategic and institutional documents related to healthcare control in Bulgaria. Results: The control system is implemented through preliminary, current (on-site/sudden), and subsequent control, planned and unplanned inspections, as well as budgetary and financial mechanisms at both micro- and macro-levels. Patient participation plays a significant role through the Electronic Health Record and the possibility to submit complaints and signals. Despite the well-developed regulatory framework, structural limitations were identified, particularly the shortage of controllers with medical education and the limited capacity for real-time control. Conclusion: The control activities of the NHIF and RHIFs represent a key instrument for ensuring transparency and financial sustainability in the Bulgarian health insurance system. Further improvement requires strengthening human resources capacity and the development of digital control tools.