Ms. Nguyen Thi Thu Hang, Deputy Director of Ho Chi Minh City Social Insurance - Photo: Provided by the character
Talking to Tuoi Tre Online about this issue, Ms. Hang said: "The refusal to examine the patient for health insurance for the second time is first due to Individual hospital staff did not understand the regulations, affecting the health and lives of patients. The hospital director must also be responsible for the mistakes of his staff."
When is it okay to refuse medical treatment?
* Many readers reported to Tuoi Tre Online that not only Phu Nhuan District Hospital refused to accept patients who came for a second health insurance examination, this story also happened in many other hospitals. What do you think about this phenomenon?
- Medical examination and treatment facilities that receive and treat patients in general and health insurance patients in particular must comply with the provisions of Article 7 of the Law on Medical Examination and Treatment, which is not to refuse when people need medical examination and treatment.
The City Social Insurance pays for health insurance examination costs according to the instructions in Clause 3, Clause 4, Article 5 of Circular 22/2023/TT-BYT of the Ministry of Health dated November 17, 2023. In which, there is no limit on the number of medical examinations but instructions on determining the number of times, price and payment for medical examinations in some cases.
* So does the medical facility have the right to refuse medical examination and treatment, madam?
- The Law on Medical Examination and Treatment also stipulates that medical examination and treatment facilities have the right to refuse to examine or treat patients if during the examination process the prognosis of the disease exceeds their capacity or is contrary to their scope of professional activities.
However, this must be reported to the competent authority or the patient must be referred to another medical facility for resolution. In this case, the practitioner must still provide first aid, emergency care, monitoring, care, and treatment for the patient until the patient is transferred to another medical facility.
In addition, medical examination and treatment may be refused if this is contrary to the provisions of law or professional ethics.
Patients waiting to get medicine at Phu Nhuan Hospital, Ho Chi Minh City - Photo: TU TRUNG
Detecting cases of "broad assignment"
* According to regulations, health insurance patients have the right to return to the hospital for examination and treatment if they feel abnormal in their health, even if they have just returned home from the examination. However, in reality, hospitals and doctors are having difficulty in paying if they do not provide reasonable explanations?
- The Social Insurance Agency shall base on the provisions of the Law on Medical Examination and Treatment, the Law on Health Insurance and other documents on health insurance, procedures and professional instructions to determine reasonable and legal medical examination and treatment costs to be paid within the scope of the health insurance fund. If health insurance examination and treatment facilities comply with the above provisions, they will not be denied payment.
If for fear of being wrong, not ensuring the rights of patients is also a violation of the Law on Medical Examination and Treatment and the Law on Health Insurance.
* There is information that the Social Insurance agency is also afraid that patients will take advantage of the Health Insurance fund, so it "tightens" hospitals during the payment process, madam?
- In fact, during the 2023 audits, we discovered cases of "wide prescription" that caused waste of the health insurance fund. The City Social Insurance and medical facilities also discovered cases of abuse of the health insurance fund, such as borrowing health insurance cards to go to medical examinations and treatment multiple times.
We also regularly coordinate with the Ho Chi Minh City Department of Health to issue documents guiding medical examination and treatment facilities to implement new regulations and documents to correct errors after appraisals, inspections and audits.
Directors of medical examination and treatment facilities are responsible for implementing and correcting, closely monitoring the implementation to reduce errors that lead to payment refusals in the following periods.
I would like to confirm that the Social Insurance agency only performs its functions and duties according to the provisions of the Law on Medical Examination and Treatment, the Law on Health Insurance and is only allowed to pay reasonable and legal medical examination and treatment costs paid within the scope of the Health Insurance Fund.
* Some readers wonder if the 3rd or 4th visit to the hospital will be covered by health insurance?
- If the patient is really sick and has to return to the hospital for examination many times (3, 4 times), first of all, we must review the expertise and quality of the medical facility. They do not guarantee quality, causing inconvenience and expense for the patient because they have to go back and forth many times.
When a patient really needs medical examination and treatment, the treating physician has appropriate instructions for the patient's condition and in accordance with regulations, Social Insurance will still pay according to the instructions in Circular 22 issued in 2023 by the Ministry of Health.
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