The quality and effectiveness of health insurance review be strengthened

20/07/2023 03:25 PM

The Vietnam Social Security (VSS) has recently issued Official Letter No. 2079/VSS-CSYT, requesting provinces and cities to strengthen health insurance (HI) review activities in their respective areas.

The letter highlights that in recent times, the implementation of HI review, prevention of abuse and exploitation of the HI fund, and protection of the rights of HI participants in localities have shown positive developments. Provinces have consistently implemented various solutions to improve the quality of HI review and control the costs of HI examinations and treatments. They have also proactively collaborated with health facilities providing health insurance services to update information on the prescribed forms according to Template 01/QTGĐ accompanying Decision No. 3618/QĐ-VSS dated December 12, 2022, issued by the of  VSS’ General Director.

However, there have recently been intricate and complex nature cases, such as the sale and fraudulent issuance of retirement certificates for receiving HI benefits, the creation of falsified medical records and documents for reimbursement from the social security office, the addition of false medical diagnoses to prescribe medication, laboratory tests, and diagnostic imaging, the excessive prescription of drugs, medical supplies, technical services, and hospital bed charges for patients who did not actually use them, the failure to ensure the rights of patients with health insurance cards, and the collection of additional fees from patients for medication and medical supplies that are already included in the daily rates for hospital beds, medical examinations, and technical services, as well as the non-compliance with regulations in maintaining contract records for HI services.

The VSS issued Official Letter No. 2079/VSS-CSYT on July 10th to enhance HI review activities at the local level. Photo: Ministry of Health

In order to effectively manage the HI fund in accordance with the law and ensure the legitimate rights and interests of HI participants, as well as improve the quality of HI verification to prevent and combat the abuse and exploitation of the social security fund and HI, the VSS has requested provinces to strictly implement certain measures, including: Strengthening control over the issuance of retirement certificates for receiving HI benefits, proactively controlling the use of the HI fund, closely monitoring the implementation of medical examination and treatment contracts, and coordinating with the Department of Health and the Department of Information and Communications to enhance the dissemination and deep understanding of the provisions of the Health Insurance Law and the Health Insurance Law.

Furthermore, strict organization and implementation of the HI review process as outlined in Decision No. 3618/QĐ-VSS dated December 12, 2022, issued by the Director-General of the VSS.

Enhancing the coordination with health facilities providing HI services in receiving and verifying HI procedures, particularly through the use of chip-embedded citizen identification cards and biometrics applications to authenticate HI cardholders, and timely detect and prevent cases of borrowing HI cards for medical treatment. Additionally, it is crucial to verify the presence of patients at healthcare facilities and the implementation of medical examinations and technical services in various departments.

Proactively and coordinating with relevant units to carry out periodic and random inspections at healthcare facilities is essential. Timely recommendations should be made to the competent authorities for handling any administrative violations in the field of health insurance as specified in Decree No. 117/2020/NĐ-CP dated September 28, 2020, issued by the Government. During the health insurance verification process, if any signs of legal violations are detected, provincial social security offices should collaborate with local police to exchange information, transfer files for verification and clarification, and proceed with legal measures.

Serious adherence to the verification topics announced by the VSS, along with updating detailed handling results in the verification software, is necessary. Proactive development of local verification topics should be implemented to enhance the effectiveness of health insurance verification activities.

Close monitoring of ensuring the rights of health insurance beneficiaries when seeking healthcare is crucial. Healthcare facilities should be requested to provide adequate medications, chemicals, medical supplies, and technical services appropriate for specialized levels as regulated by the Ministry of Health. Particularly, the situation where health insurance beneficiaries have to pay for healthcare costs within their entitled scope and benefits should be prevented.

The temporary advances and settlement of health insurance costs should be carried out in accordance with the provisions stated in Article 32 of the Health Insurance Law and the guidance documents issued by the VSS.

Enhancing the capacity and responsibility of officials and employees involved in health insurance verification is important. Regular review, inspection, and cross-referencing of health insurance costs with the reimbursement regulations should be conducted. Firmly rejecting and recovering any improper or unauthorized healthcare costs is essential. Taking responsibility for the accuracy of cost settlement and reimbursement data regarding healthcare costs from healthcare facilities providing health insurance services is crucial. Negative behaviors during the health insurance verification process are strictly prohibited.

Proactive coordination with the Department of Health and healthcare facilities providing health insurance services is necessary to promptly address any emerging issues within their jurisdiction.

The VSS also requests provincial and municipal social security agencies to develop plans, organize meetings, and provide regular training to improve professional skills and expertise for officials and employees involved in health insurance verification at the provincial and district levels.