(HBO) - Assessing the costs of medical examination and treatment coverd by health insurance is an important task of the social insurance agency in order to manage and use the health insurance fund transparently and publicly, ensuring the interests of the participants. In particular, putting the information system of health insurance assessment into operation has an important meaning, contributing to improving the efficiency of health insurance assessment.

In the context of the current 4.0 revolution, the application of technology and computerization is a mandatory requirement, as well as the basis and motivation for renewing health insurance assessment activities in a modern and professional direction. the information system of health insurance assessment has achieved the practical results, contributing to changing the consciousness and improving the responsibility of managing the health insurance fund not only of the social insurance but also the health sector, especially the medical facilities. With the information system of health insurance assessment, the provincial social insurance agency has linked the data of medical examination and treatment at all of the health facilities from the commune to the provincial level with a total of 232 facilities. All data on the request for payment of health care and health insurance premiums submitted by the medical facilities to the system is encrypted and strictly managed, ensuring safety and confidentiality of information according to the regulations. The data on the payment request from the hospitals are automatically assessed by the system using a set of rules based on the regulations and professional technical processes of the Ministry of Health. 

The violating records are automatically rejected or marked with a warning for the examiner to directly re-examine on the medical record. Thereby, the assessors can quickly and promptly detect the medical care costs that have been requested to pay are not in accordance with the regulations or are inconsistent with the diagnosis. the information system of health insurance assessment is also linked with other professional software of the social insurance to issue the warnings on monitoring software for the medical examination covered by health insurance, helping the assessors to promptly check and review the cases using the health insurance card for medical care related to the dead patients and for the medical examination and treatment many times a day...

Mr. Nguyen Ngoc Son, the director of the provincial social insurance agency, says: Through the functions of the system, the social insurance agency has carried out the assessment and discovered the wrong costs, recovered the fund for medical examination and treatment covered by health insurance in many cases of non-compliant payment such as: the payment for the technical services is in the professional and technical process of other technical services or neutral payment; the payment for the wrong date bed, the wrong classification surgery; the payment for the prescribed drugs that are not in accordance with the instructions for use and the payment conditions; splitting up the course of prolonged inpatient treatment or medical examination and treatment with the multiple doses of antibiotics; the payment of costs for diagnosis and treatment of Covid-19 from the wrong source... Through the assessment information system (the active assessment and automatic assessment), the total amount refused to pay to the medical facilities and about 11.6 billion VND was recoverd to the health insurance fund in 2021; over 5 billion VND in 2022; over 30 million VND in the first quarter of 2023.

The updated, public, transparent information about the medical care situation has helped the local social insurance agencies have an overview and easily identify and quickly detect the changes and developments in the costs for medical care covered by health insurance at all of the medical facilities to promptly coordinate with the medical facilities in controlling and using the health insurance fund effectively. Many medical facilities have made the positive changes in treatment indications, contributing to reducing the unnecessary expenses. In addition, the data of the health care covered by health insurance have also become the main source of information in the policy development, helping to assess the impact and adjust the policies, developing new methods of health insurance payment by capitation and diagnostic groups, evaluating and selecting new drugs and technologies into the benefit package for health insurance.

According to the statistics of the provincial social insurance agency, it is estimated that by the end of June 2023, the whole province has nearly 500,000 medical care visits with health insurance, of which the number of outpatients is over 445 thousand, and inpatients are over 54,000. The amount of medical and health care expenditures covered by health insurance in the province is estimated at 312 billion VND (126 billion VND for outpatient care, 186 billion VND for inpatient care) by the end of June 2023. In addition, health care expenses covered by health insurance for over 26,000 medical and health care visits are covered by health insurance outside the province (patients treated in other provinces) with a total amount of 22.5 billion VND. In addition to the regular medical care costs, the health insurance fund also covers many serious and chronic diseases. Many patients are paid billions of dongs by the health insurance fund, thereby it helps the patients and their families overcome the economic difficulties to treat their diseases with peace of mind, demonstrating the sharing nature of health insurance.

It can be affirmed that the operation of the information system of health insurance assessment of the social insurance has brought practical benefits to the participants, the medical facilities, the social insurance agencies and in the management and administration of the health insurance fund, completing the health insurance policy. Thereby, the health insurance policy increasingly clearly shows the role, the value and great benefits of the health insurance card for people's health care.