People need to know: Health Insurance appraisal information system contributes to transparent management of Health Insurance fund

In recent times, the work of health insurance appraisal has been continuously innovated and improved by the Vietnam Social Insurance sector, especially the operation of the Health Insurance Appraisal Information System (since 2017) is considered a breakthrough in improving the efficiency and effectiveness of health insurance appraisal work.

Public and transparent payment of medical examination and treatment costs

With the Health Insurance appraisal information system, the Vietnam Social Insurance sector has connected and interconnected health insurance examination and treatment data at all medical facilities from commune to central levels nationwide. All data requesting payment for health insurance examination and treatment sent by medical facilities to the System are encrypted, strictly managed, ensuring safety and confidentiality of information according to regulations. Payment request data is automatically appraised using a set of rules based on regulations and professional technical processes of the Ministry of Health. Violations are automatically rejected or marked for direct appraisal on the medical record. Thereby, helping the Social Insurance agency quickly and promptly detect medical examination and treatment costs that medical facilities request for payment that are not in accordance with regulations or are not appropriate and need to be focused on appraisal.

Performing a kidney transplant for a patient at Nghe An General Hospital. Photo: Document

Through the functions of the System, many cases of illegal payments have been quickly detected such as: illegal payment of hospital beds; payment for services within the technical process; duplicate payments; incorrect surgical classification; payment for prescribed drugs not in accordance with instructions for use and payment conditions; splitting treatment periods, prolonging inpatient treatment days; excessive inpatient treatment; multiple medical examinations and treatments, duplicate medication; payment statisticsHealth insurancenot true for Covid-19 cases…

On the other hand, the implementation of System connectivity with other industry softwareSocial insuranceVietnam to build a warning map on the Health Insurance Examination and Treatment Monitoring Software so that the Social Insurance of the provinces can promptly check and review cases of using Health Insurance cards for medical examination and treatment related to deceased patients: in 2021, 353 medical examinations and treatments were warned, in the first 6 months of 2022, 202 medical examinations and treatments were warned.

Health insurance cards greatly support people in the process of medical examination and treatment. Photo: Thanh Cuong

Results of Health Insurance appraisal work in 2021 and the first 6 months of 2022. The Health Insurance appraisal information system has recorded deductions for health insurance examination and treatment costs as follows:

- 2021: deduction of 1,185 billion VND (of which proactive appraisal deducted 1,143.3 billion VND, automatic appraisal deducted 41.7 billion VND).

- First 6 months of 2022 (data updated on July 14, 2022): deduction of VND 255.3 billion (active appraisal VND 168.1 billion, automatic appraisal VND 87.2 billion).

Number of medical examinations and treatments covered by health insurance and medical examination and treatment costs paid by the Social Insurance agency in the last 3 years are as follows:

Number of medical examinations and treatments covered by health insurance and medical examination and treatment costs paid by the Social Insurance agency for the patient.

Health Insurance Fund pays billions to many patients with serious illnesses

In recent times, in addition to paying for regular medical examination and treatment costs, the Health Insurance Fund has also paid for many cases of serious illness and chronic illness, including many patients who have received billions of dong in hospital expenses from the Health Insurance Fund, thereby helping patients and their families overcome economic difficulties to feel secure in their treatment.

The Health Insurance appraisal information system contributes to effective and transparent management of the Health Insurance fund.

According to statistics, in 2021, nationwide, 57 patients were paid medical examination and treatment costs of over 1 billion VND by the Health Insurance Fund; in the first 6 months of 2022, nationwide, 15 patients were paid medical examination and treatment costs of over 1 billion VND by the Health Insurance Fund. Of which, from 2021 to the end of June 2022, there were 04 patients who were paid over 3 billion VND by the Health Insurance Fund, specifically:

- The patient who received the highest payment from the Health Insurance Fund of more than 3.9 billion VND: card code BT2868621XXXXXX, born in 1984, address Trung Trach hamlet, Trung Thanh commune, Vung Liem district, Vinh Long province, main diagnosis is "Hereditary factor VIII deficiency".

- The patient who received the second highest payment from the Health Insurance Fund, over 3.3 billion VND: card code TE1343422XXXXXX, born in 2017, address group 15, De Tham ward, Thai Binh city, Thai Binh province, main diagnosis is "Glycogen storage disease; Other metabolic disorders".

- The patient who received the third highest payment from the Health Insurance Fund, nearly 3.09 billion VND: card code BT2202020XXXXXX, born in 2006, address Hoang Dong commune, Lang Son city, Lang Son province, main diagnosis is "Hereditary factor VIII deficiency".

- The patient with the 4th highest health insurance payment of nearly 3.05 billion VND: Card code TE1262621XXXXXX, born in 2018, address Tho Tang town, Vinh Tuong district, Vinh Phuc province, main diagnosis is "Glycogen storage disease; Pyruvate metabolism disorder and gluconeogenesis".

It can be affirmed that the operation of the Health Insurance Assessment Information System of the Vietnam Social Insurance sector has brought practical benefits to participants, medical examination and treatment facilities, Social Insurance agencies and in the management and operation of the Health Insurance fund, perfecting the Health Insurance policy. Thereby, the Health Insurance policy has increasingly demonstrated the role, value and great benefits of the Health Insurance card for the health care of the people./.