The workshop aims to disseminate and issue guidelines on the key contents of the implementation of medical claim review in accordance with the new review protocol; issue guidelines on the implementation of medical review software functions in line with the new review protocol promulgated together with Decision No 3618/QĐ-BHXH dated December 12, 2022; discuss and share experience about the settlement of difficulties, and shortcomings in the implementation of medical claim review; and enhance the medical claim review efficiency and effectiveness of medical reviewers.

Accordingly, the new review protocol provides guidelines on two types of review carried out in parallel:  proactive medical claim review (directly conducted by social security offices); and automated medical claim review (using software to verify the electronic database). The new medical review protocol also provides detailed guidelines on reviewing health insurance-covered medical costs: reviews based on data analysis; reviews based on medical records, documents and other findings; and reviews based on direct payments.

A representative from the Centre for Medical Claim Review said the Medical Claim Review Information System has been operating since 2017 and has connected health insurance-covered medical examination and treatment data from more than 13,000 medical facilities from commune to Central levels nationwide. The system includes a data portal; review software (which has been integrated in line with the Medical Review Protocol issued together with Decision No 3618/QĐ-BHXH); and drug supervision and management software (centralised drug supply management and regulation).

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Participants learn about the new medical review protocol

At the workshop, participants heard reports on eight topics, namely: an introduction of functions of the review software in line with Decision No 3618/QĐ-BHXH; updated information on signing health insurance-covered medical examination and treatment contracts; reviewing conditions for the reimbursement of medicine, technical services, and medical material and equipment costs; reviewing health insurance-covered medical examination and treatment costs on data; processing review results; direct and multiline payment; integration of payment and information exploitation management software in the Medical Review Information System; and key contents in the implementation of the medical review protocol promulgated together with Decision No 3618/QĐ-BHXH.

Of note, the integration of payment and information exploitation management software in the Medical Review Information System was also presented separately, so were key contents related to the implementation of the new medical claim review protocol (which was issued by the VSS in late 2022).

All the topics were discussed and analysed to have a clear comparation between the previous and present software, between the old and new operation, and between theory and practice. The discussions were managed by representatives from the Centre for Medical Claim Review and the Department of Health Insurance Implementation (Vietnam Social Security), to make sure the Health Insurance Fund is used legally and efficiently.

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The new medical review protocol is put into use as of January 1, 2023

Accordingly, the medical claim review relies on the methods, tools and people. Therefore, to satisfy the current requirements, VSS has issued a new medical review protocol (method), new medical review software (tool), and is currently conducting a training workshop to enhance the efficiency and effectiveness of the medical reviewers (people).

Through the workshop, participants are made aware of the key contents of the implementation of the new medical review protocol. Additionally, the participants must be proficient in the implementation of the new medical review protocol. With the above-mentioned requirements, each participant directly practised on computers. The event also enabled participants to connect with each other and share experiences in dealing with difficulties and obstacles, among others.

The training workshop on medical review software in the South takes place over two two-day sessions, with participants coming from social security offices in 13 provinces and cities. The event is expected to end on March 24. Previously, VSS organised a similar event in the North and Central regions.