Effective 'filter' in health insurance appraisal

(Baonghean) - The Health Insurance Appraisal Information System has been deployed by Vietnam Social Security since July 1, 2016, and is an effective support tool used to monitor and warn of unusual problems, providing information to medical facilities to improve and ensure the rights of patients. Up to now, Nghe An has been assessed as one of the leading provinces in effectively implementing the system.

Many violations were discovered

After more than 1 year of operation, connecting with 541 medical examination and treatment facilities (2017), the health insurance appraisal information system in Nghe An has "revealed" many unreasonable costs in health insurance examination and treatment, signs of profiteering from the health insurance fund from the health insurance card users themselves in the context of increasingly "open" health insurance policies.

Among them, there are many typical cases of law violations detected and warned by the system, helping social insurance officers intervene in a timely manner, such as 4 cases of applying for fake birth certificates, birth certificates, and changing the time of birth to enjoy maternity benefits, discovered not long ago in the districts of Quy Hop, Thanh Chuong, and Do Luong.

Specifically, 2 out of 4 violations mentioned above are in Quy Hop district. The case of Thai Thi Le (born in 1990), belongs to Phu Quy Stone and Mineral Joint Stock Company. In the maternity payment records of Thai Thi Le, it shows that Le gave birth on April 3, 2017 at Chau Cuong Commune Health Station, Quy Hop district.

However, through checking the software data of the Health Insurance Appraisal Information System Data Receiving Portal, the appraiser discovered that, in fact, Thai Thi Le gave birth at the Northwest Regional General Hospital on March 1, 2017.

Social insurance officers verified at Chau Cuong Commune Health Station and the commune health station admitted: Le did not give birth at the commune health station on April 3, 2017; Birth certificate No. 09, book No. 01/2017 issued by the commune health station to Thai Thi Le who gave birth on April 3, 2017 was fake and not in accordance with regulations.

Staff of the Provincial Health Insurance - Social Insurance Appraisal Department conduct appraisal on the system. Photo: Phuoc Anh

Previously, the health insurance appraisal information system had effectively supported the appraisal staff, raising warnings and questions about many patient records created by the Tuong Son Commune Health Station (Anh Son). Data on the appraisal portal showed that a number of patients continuously came for medical examination and treatment, but these people affirmed that they had never been to the health station.

Based on this sign, Social Insurance officers inspected nearly 1,300 health insurance payment request lists of Tuong Son Medical Station in less than 3 months (from the beginning of April to June 21, 2017), and determined that this station had created 153 lists of medical examination and treatment costs and prescriptions without any patients in reality.

The incident shocked public opinion. The Head of the Tuong Son Commune Health Station was later given a disciplinary warning, and the remaining 5 officers of the station were also disciplined with a reprimand. The amount of the violation was also fully reimbursed.

Also from the health insurance appraisal information system, the Social Insurance industry has quickly detected and refused to pay many records due to incorrect health insurance card information, incorrect benefit levels, duplicate payment requests or prescriptions for drugs, medical supplies, and technical services outside the scope of health insurance benefits, and incorrect coding of shared categories...

In addition, the connection and data exchange also helps to detect and count many "records" of the number of medical examinations of health insurance patients. Typically, Mr. Tran Huy H. went to the hospital 207 times, the amount of money paid by the health insurance fund was more than 36.2 million VND; Mr. Nguyen Huu N. had 149 medical examinations, the health insurance fund paid up to 70 million VND. Both have permanent residence in Vinh City.

Fast and effective

The above cases partly show the practical effectiveness of the health insurance appraisal information system. It is known that this is the first time the social insurance industry has an information technology application service that connects with the entire health system in a synchronous manner.

According to the design, the system includes 3 components: Health Insurance Payment Request Receiving System; Health Insurance Appraisal System; Shared List System. Particularly for the Health Insurance Appraisal System, the appraisal software has the function of detecting errors, "filtering" errors according to the system in the payment request file of the medical examination and treatment facility. The software is built, providing statistical functions to detect whether these errors are individual or common, in order to make appropriate adjustments.

Diagram of health insurance appraisal information system.

Mr. Phan Duy Cuong - Deputy Head of Health Insurance Appraisal Department, Social Insurance of Nghe An province said that the number of appraisers in the whole province is only about 100 people, while the workload is very large. Therefore, the birth of the health insurance appraisal information system is the optimal solution in managing medical examination and treatment and payment of health insurance examination and treatment costs, creating convenience, publicity and transparency in health insurance fund management. Since the system was established, the work has been resolved smoothly and quickly, if done manually as before, it would take a lot of time and human resources.

Mr. Phan Duy Cuong said that Nghe An is the third province in the country in terms of the number of facilities connected to the system; the first in the country in terms of the rate of transferring medical examination and treatment records to the system; and the top in the country in terms of implementing uniform payment and data settlement procedures with medical examination and treatment facilities.

The health insurance appraisal information system also brings many benefits to the people. Accordingly, people will have reduced administrative procedures and shortened time for medical examination and treatment. Along with the Ministry of Health updating the test results of each file on the data portal, patients transferred to other facilities will not have duplicate indications in testing and paraclinical indications. Medical examination and treatment facilities can exploit the patient's medical history and test results to make appropriate indications; at the same time, manage and prevent the situation of taking advantage of the health insurance fund; reduce the time to synthesize and prepare reports according to the regulations of the Ministry of Health and the Ministry of Finance...

The health insurance appraisal information system is considered a big step forward for the social insurance industry. Mr. Pham Luong Son - Deputy General Director of Vietnam Social Insurance affirmed that the operation of the health insurance appraisal information system ensures publicity and transparency in the implementation of health insurance examination and treatment.

“This openness and transparency is reflected in the fact that the system allows medical staff and social insurance to access and monitor information. The health sector and social insurance need to use this tool effectively to serve patients, ensuring the best interests of patients.” The Deputy General Director of Vietnam Social Insurance also said that in order to meet practical requirements, the appraisal information system needs to be continuously updated and upgraded, aiming for fairness and ensuring greater efficiency not only for the people but also for the implementing organizations.

Phuoc Anh