Why has more than 8 billion VND in health insurance not been paid for 6 years at Gia Lai General Hospital?

Gia Lai Provincial General Hospital has been "stuck" with 8.3 billion VND in health insurance medical examination and treatment fees since 2018 that have not been paid yet - Photo: TAN LUC

On May 30, Gia Lai Provincial Social Insurance explained about the failure to pay VND 8.3 billion for health insurance examination and treatment at Gia Lai Provincial General Hospital since 2018.

According to Gia Lai Provincial Social Insurance, in 2018, the Provincial General Hospital exceeded the estimated health insurance medical examination and treatment expenditure by over 40 billion VND.

Of which, 32 billion VND exceeded the estimate but did not exceed the ceiling and was paid by the insurance agency according to regulations.

The remaining 8.3 billion VND exceeded the estimate and the multi-level ceiling. The hospital also explained, but because the factors leading to exceeding the ceiling have not been fully determined, the insurance has no basis for payment.

According to the explanation of Gia Lai General Hospital, the reason for exceeding the ceiling is because in 2018 the hospital changed its functions and tasks, no longer having a pediatric department.

This resulted in a higher average cost of treatment per patient compared to the previous year (pediatric patients have lower average medical costs than adult patients). However, the calculation of average costs for payment by the insurance agency without distinguishing between pediatric and adult patients is inappropriate.

Meanwhile, Gia Lai Provincial Social Insurance believes that the responsibility for exceeding the multi-level ceiling belongs to the Provincial General Hospital.

Up to now, after many explanations, the hospital has determined that out of the multi-level ceiling of more than 8.3 billion VND in 2018, 3.25 billion VND was due to objective reasons. The remaining 5 billion VND has no objective reason.

Therefore, the hospital requested the insurance agency to consider paying the amount exceeding the ceiling due to objective reasons of 3.25 billion VND.

Up to now, Gia Lai Provincial Social Insurance has proposed Vietnam Social Insurance to pay additional costs exceeding the multi-level ceiling until 2018 in the amount of 3.25 billion VND. The remaining amount of excess ceiling is due to the hospital not being able to explain a reasonable reason, so the insurance agency has no basis for payment.

Source: https://tuoitre.vn/vi-sao-6-nam-chua-thanh-toan-hon-8-ti-dong-bao-hiem-y-te-tai-benh-vien-da-khoa-gia-lai-20240530090918134.htm