How will the 7,000 billion VND of health insurance that has not been settled for hospitals be handled?

Social insurance agencies will review the portion of hospital expenses that have not been settled due to exceeding the total health insurance coverage limit; any portion within the budget will be covered, while the remainder will be submitted for approval from the competent authority.

On November 17th, the Vietnam Social Security agency announced that it is requesting local authorities to review the excess funds exceeding the total health insurance payment limit for medical examinations and treatments in 2019, 2020, and 2022, in order to disburse payments to hospitals according to the new regulations in Decree 75. In 2021 alone, over 4,300 billion VND exceeding the total payment limit has already been settled.

A day earlier, medical facilities collectively reported that outstanding health insurance claims exceeding the total amount had not been settled, resulting in a shortage of funds for purchasing medical supplies and delays in payment for contracted services, thus affecting medical examinations and treatments. According to preliminary statistics from the Social Insurance agencies of 63 provinces and cities, the total amount of outstanding claims is over 7,000 billion VND. This includes costs related to medical service prices, drugs, chemicals, medical supplies, blood, and blood products (not included in service prices) used for patients.

The situation originated in 2019, when the Social Insurance agency settled health insurance medical examination and treatment costs with hospitals using the total payment method stipulated in Decree 146 issued in 2018. Specifically, quarterly, the Social Insurance agency audited and provisionally settled payments for hospitals based on the quantity and price of medical services and the costs of medicines, chemicals, medical supplies, blood, and blood products used for patients.

However, when settling accounts at the end of the year, the Social Insurance Fund bases its calculations on the total payment amount (determined based on the total payment amount of the immediately preceding year). This creates difficulties for hospitals because, in reality, the total cost of medical examinations and treatments in the following year is always higher than the previous year. The total payment amount for medical examinations and treatments under health insurance, as stipulated, is much lower than the actual costs incurred by healthcare facilities for patients. As a result, costs exceeding the total payment amount will not be covered by the Health Insurance Fund.

Inside the A9 Emergency Department, Bach Mai Hospital, November 2022. Photo: Ngoc Thanh — Inside the A9 Emergency Department, Bach Mai Hospital, November 2022. Photo: *Ngoc Thanh*

Decree 75, issued in October 2023, amends and supplements Decree 146, abolishing the regulation on the total payment amount for health insurance medical examination and treatment costs, and implementing payment based on actual costs. Hospitals are notified of the projected health insurance medical examination and treatment expenses as a basis for planning the use of funds for the year. This decree takes effect from December 3rd, but the content abolishing the regulation on the total payment amount is retroactively effective from January 1st, 2019.

"Most of the outstanding costs related to mechanisms and policies concerning the total amount from 2019 to 2022 will be resolved," a representative of Vietnam Social Security said.

Therefore, out of the trillions of dong that have not yet been settled, any amount within the budget will be covered by the Health Insurance Fund according to the new regulations. For amounts exceeding the budget but not included, a report will be submitted to the competent authority for approval. Payments will begin in early December when the decree takes effect.

Vietnam's Social Insurance agency believes that the Health Insurance Fund has limited resources. Abolishing the regulation on the total reimbursement amount for health insurance medical examination and treatment costs will create many new challenges in controlling cost increases and preventing abuse and fraudulent exploitation of the fund.

Hong Chieu

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