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

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 expenses for medical examination and treatment under health insurance (HI) 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 payments have 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 the contract, 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 the service price) 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 Fund bases on the total payment (determined based on the total payment of the previous year). This causes difficulties for hospitals because in reality, the total medical examination and treatment costs of the following year are always higher than the previous year. The total medical examination and treatment costs under the Health Insurance Fund as prescribed are much lower than the actual costs that the facilities have used for patients. As a result, costs exceeding the total payment 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 amending and supplementing Decree 146 abolished the regulation on total payment for health insurance examination and treatment costs, and implemented 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 total payment 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, the amount that is in the budget will be paid by the Health Insurance Fund according to the new regulations. The amount that exceeds but is not in the budget will be reported to the competent authority to request 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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