Social insurance reviews the unsettled hospital expenses due to exceeding the total health insurance examination and treatment costs. The part that is within the budget will be paid, and the rest will be consulted with the competent authority.
On November 17, Vietnam Social Security said it was requesting local vertical sectors to review the excess budget for health insurance (HI) medical examination and treatment in 2019, 2020 and 2022 to pay hospitals according to new regulations in Decree 75. In 2021 alone, more than VND4,300 billion in excess of the total payment has been resolved.
A day ago, medical facilities reported that they had not yet settled their health insurance payments in excess of the total amount, resulting in a lack of money to purchase supplies and delays in payment of bid packages, affecting medical examination and treatment. According to preliminary statistics from the Social Insurance agencies of 63 provinces and cities, the total amount that has not been settled is more than 7,000 billion VND. This amount includes costs related to medical service prices, costs of 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 settled the cost of health insurance examination and treatment with hospitals according to the total payment method as Decree 146 issued in 2018. Specifically, every quarter, the Social Insurance appraised and temporarily settled for hospitals determined by the quantity, price of medical services and costs of drugs, chemicals, medical supplies, blood, and blood products used for patients.
However, when settling the year, the Social Insurance base on the total payment (determined based on the total payment of the previous year). This causes difficulties for hospitals because in reality, the total cost of medical examination and treatment of the following year is always higher than the previous year. The total payment for medical examination and treatment under the Health Insurance according to regulations is much lower than the actual cost that the facilities have used for patients. As a result, the cost exceeding the total payment will not be paid by the Health Insurance Fund.
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 of health insurance examination and treatment costs, and implementing payment based on actual costs. Hospitals are notified of the estimated amount of health insurance examination and treatment costs as a basis for planning the use of funds during the year. This Decree takes effect from December 3, but the content abolishing the regulation on the total payment level is applied retroactively, from January 1, 2019.
"Most of the costs related to the mechanism and policies related to the total amount from 2019 to 2022 will be resolved," said a representative of Vietnam Social Security.
Thus, of the thousands of billions of VND that have not been settled, any amount that is included in the budget will be paid by the Health Insurance Fund according to the new regulations. Any amount that exceeds but is not included in the budget will be reported to the competent authority for approval. Payment will be made from the beginning of December when the decree takes effect.
Vietnam Social Security believes that the Health Insurance Fund is limited. The abolition of the regulation on the total payment of health insurance medical examination and treatment costs will create many new challenges in controlling rising costs and preventing abuse of the fund.
Hong Chieu
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