Ensuring safe and effective management and use of health insurance funds

To ensure balance, management and safe and effective use of health insurance funds, the Social Insurance agency strives to effectively organize and implement health insurance appraisal as well as inspection and examination.

Social Insurance Agency appraisal at Ngo Quyen General Hospital.

Cost increase

According to information from the City Social Insurance, the city has more than 3.7 million people participating in health insurance. In the first 6 months of 2025, the number of health insurance examinations and treatments in the city was more than 2.8 million, an increase of more than 123,600 people compared to the same period in 2024 (equivalent to a rate of 4.55%). The total expenditure on health insurance examinations and treatments in 6 months was more than VND 2,400 billion, an increase of more than VND 268 billion compared to the same period in 2024 (equivalent to a rate of 12.52%) and equivalent to more than 52% of the annual estimate. Specifically, there were nearly 2.5 million outpatient examinations and treatments with a total health insurance expenditure of more than VND 890 billion (an increase of 13% over the same period); nearly 350,000 inpatient examinations and treatments, with a total cost of more than VND 1,500 billion (an increase of 12.2%). Of which, the inpatient treatment rate is 12.97% (higher than the national average of 10.08%); the average inpatient treatment days are 7.01 days/time (higher than the national average of 0.46 days).

The above data shows that the increase in expenditure is due to objective reasons such as the sudden increase in the number of people seeking medical examination and treatment, but the health insurance fund still ensures full and timely payment for patients.

Notably, in the organization and implementation of health insurance medical examination and treatment, there are still some difficulties and problems, such as: some facilities are still updating and standardizing the list of errors, sending medical examination and treatment data is slow, the situation of high cost increase in some facilities... According to statistics, there are more than 127,000 records sent late (equivalent to a rate of 3.9%), some medical facilities have a very low rate of correct date, below 90%. Some hospitals have high treatment time such as: Hai Duong Rehabilitation Hospital, Hai Duong Tropical Diseases Hospital... In addition, there are nearly 175 billion VND of costs exceeding the estimate that have not been paid due to the lack of appraisal instructions from the Ministry of Health.

According to the analysis, the cost of medical examination and treatment under health insurance increased compared to the same period in 2024 because from July 1, 2024, the basic salary increased to VND 2.34 million/month, leading to the cost of a medical examination and treatment that health insurance participants do not have to pay co-payment will increase from VND 270,000 to VND 351,000. The increase in hospital fees is regulated in Circular No. 21/2024/TT-BYT dated October 17, 2024 of the Ministry of Health stipulating the method of pricing medical examination and treatment services. Along with that, from January 1, 2025, the Law amending and supplementing a number of articles of the Law on Health Insurance took effect with a number of new points, such as: inpatients are entitled to 100% of the cost of medical examination and treatment according to health insurance benefits (technical expertise is the basic level), which partly leads to an increase in the rate of inpatient admission; Patients receive 100% of the cost of medical examination and treatment covered by health insurance at medical examination and treatment facilities at the initial medical examination and treatment level...

Social Insurance Agency appraisal at Hanoi Eye Hospital - Hai Phong.

Tight control

In the context of implementing the health insurance policy under the two-tier local government model, the workload is increasing, especially the number of people participating and receiving medical examination and treatment under health insurance is increasing, requiring stricter management of the health insurance fund in the coming time. Deputy Director of Hai Phong Social Insurance Bui Van Ha said that the unit organizes health insurance appraisal according to regulations; coordinates with medical facilities to ensure the rights of health insurance patients, promptly resolves problems and creates the most favorable conditions for patients when going for medical examination and treatment; effectively uses the 2025 health insurance medical examination and treatment budget (Decision 472/TTg) and completes the settlement of the first quarter of 2025 and the second quarter of 2025 on time. In addition, the Social Insurance agency has done a good job of inspecting, checking and recovering to the health insurance fund more than 980 million VND due to not meeting the payment conditions.

For the health sector, to ensure the conditions for health insurance examination and treatment for people, the sector has also implemented many solutions, such as: issuing new codes, adjusting information after the merger, allocating health insurance cards; implementing centralized drug bidding in the period of 2025-2026 to ensure the supply of health insurance examination and treatment drugs; reusing medical supplies according to the instructions of Circular 04/2017/TT-BYT, ensuring safety and savings. At the same time, requiring medical examination and treatment facilities to submit health insurance assessment data in compliance with the time limit, avoiding sending at the end of the month causing system congestion; updating Update catalog and information code medical examination and treatment facilities, supplement bed codes, technical lists, equipment... to avoid automatic deductions. Along with that, build hospital admission standards suitable to the actual capacity of each facility according to regulations, handle abnormally high medical examination and treatment costs when there is a warning from the Social Insurance agency... to optimize the efficiency of using the health insurance fund.

In the coming time, it is forecasted that health insurance appraisal work will continue to face many difficulties due to increased workload and the need to streamline the apparatus. In response to this reality, the City Social Insurance assigned health insurance appraisal staff to proactively propose effective fund management solutions and control medical examination and treatment costs more closely to ensure fund balance according to the budget assigned by Vietnam Social Insurance.

According to Deputy Director of Hai Phong Social Insurance Phan Nhat Minh, Social Insurance facilities comply with regulations in the work of appraisal and settlement of health insurance, especially in controlling medical examination and treatment costs; regularly urge, remind and warn health insurance medical examination and treatment facilities about the contents of health insurance medical examination and treatment costs increasing compared to the same period.

HOANG XUAN

Source: https://baohaiphong.vn/bao-dam-quan-ly-su-dung-quy-bao-hiem-y-te-an-toan-hieu-qua-519320.html