Health insurance assessment information system contributes to effective and transparent management of the health insurance fund

30/07/2022 01:45 PM

HA NOI Assessing medical examination and treatment costs covered by health insurance helps to ensure transparent and effective management and use of the health insurance fund.

The assessment also contributes to ensuring the maximum legal and reasonable interests of health insurance card holders.

Health insurance assessment has been continuously innovated and perfected by Vietnam Social Security, especially the operation of the health insurance assessment information system which was launched in 2017 and is considered a breakthrough in improving the efficiency of health insurance assessment.

With the Health Insurance Assessment Information System, Vietnam Social Security has linked health insurance data at all health facilities from the commune to the central level nationwide. All data submitted to the system by medical facilities for medical treatment and health insurance payment is encrypted and strictly managed, ensuring the safety and confidentiality of information according to regulations.

The payment request data is automatically verified by a set of rules based on the regulations and professional processes of the Ministry of Health. Violation records are automatically rejected or marked so that the assessment can be made directly on the medical record. Thereby, the social insurance agency can quickly and promptly detect unlawful medical care expenses that medical establishments requested to pay.

General Director of Vietnam Social Secury Nguyen The Manh inspects the Health Insurance Assessment Information System

Through the system, many cases of illegal payment were detected quickly, such as the incorrect payment of hospital beds; duplicate payments; wrong classification of surgery; payment of prescribed drugs not in accordance with the instructions for use and payment conditions; split treatment sessions, prolonged inpatient treatment days; indication for unnecessary inpatient treatment; repeated medical examination and treatment, duplicate drugs; and incorrect health insurance payment for COVID-19 cases.

The connection of the assessment information system with other professional software of Vietnam Social Security also helps to build a warning map on the Health Insurance Medical Care Monitoring Software so that the provincial social insurance agencies can promptly check and review the cases of using health insurance cards of dead people. In 2021, 353 cases of such violations were detected. In the first six months of 2022, 202 cases were found.

The health insurance assessment information system has recorded the deduction of medical and health insurance costs. In 2021, VND1.185 trillion was deducted. In the first six months of 2022 (data updated on July 14, 2022), VND255.3 billion was deducted.

Health insurance fund pays billions for many critically ill patients

In addition to paying for normal medical care costs, the health insurance fund also pays for many serious and chronic diseases. Many patients received health insurance totalling billions of dong.

According to statistics, in 2021, the whole country has 57 patients to which the health insurance fund paid medical costs of over VND1 billion. In the first six months of 2022, 15 patients nationwide had medical expenses of over VND1 billion covered by the health insurance fund.

From 2021 to the end of June 2022, there were four patients covered by the health insurance fund for over VND3 billion.

Specifically, a patient born in 1984, in Trung Trach hamlet, Trung Thanh commune, Vung Liem district, Vinh Long province, with "Factor VIII deficiency (hemophilia A)”, had the highest amount covered by the health insurance fund at more than VND3.9 billion.

The patient with the second highest payment by the health insurance fund, over VND3.3 billion, was born in 2017, in De Tham ward, Thai Binh city, Thai Binh province, for "Glycogen accumulation disease and other metabolic disorders”.

The patient with the third highest payment by the health insurance fund, nearly VND3.09 billion, was born in 2006, in Hoang Dong commune, Lang Son city, Lang Son province, for "Factor VIII deficiency (hemophilia A)”.

Every year, many patients have high medical costs covered by the health insurance fund

The patient with the 4th highest payment by the health insurance fund, nearly VND3.05 billion, was born in 2018, in Tho Tang town, Vinh Tuong district, Vinh Phuc province, for the main diagnosis of "Cumulative glycogen disease and disorders of pyruvate metabolism and gluconeogenesis."

The operation of the health insurance assessment information system of Vietnam Social Security has brought practical benefits to participants, medical facilities, social insurance agencies and health insurance fund management agencies.

Thereby, the health insurance policy has increasingly clearly demonstrated the role, value and great benefits of the health insurance card for people's healthcare./.