NGHIÊN CỨU TÌNH HÌNH CHI PHÍ BỊ TỪ CHỐI THANH TOÁN TRONG KHÁM VÀ ĐIỀU TRỊ BẢO HIỂM Y TẾ VÀ KẾT QUẢ CAN THIỆP TẠI BỆNH VIỆN ĐA KHOA MEDIC BÌNH DƯƠNG NĂM 2023 – 2024

Abstract

Background: In Vietnam, service-based payment remains the primary method used for health insurance examination and treatment services. The increasing refusal of payment for health insurance medical expenses poses challenges for healthcare facilities. Objectives: 1) To determine the rate of refused payment costs in health insurance examination and treatment at Medic Binh Duong General Hospital in 2022-2023. 2) To identify some reasons for the refusal of payment costs in health insurance examination and treatment. 3) To evaluate the intervention results regarding refused payment costs in health insurance examination and treatment. Materials and methods: The study uses a descriptive retrospective method combined with a non-controlled intervention on all cost verification records of patients' examinations and treatments. Results: During the period from April 2022 to March 2023, cost verification for health insurance examination and treatment was conducted on 140,472 records submitted for payment, with 6,654 records (accounting for 4.5%) being refused payment. Common reasons for refusal included:administrative costs and procedural/surgical costs. After intervention, from July 2023 to December 2023, among 86,947 records submitted for health insurance payment, 1,546 records (accounting for 1.8%) were refused payment. The rejection rate of claims significantly decreased after the intervention, with the intervention effectiveness index of inpatient treatment forms being 40.9%, outpatient treatment forms being 62.5%, and overall being 60.7% (p<0.001). Conclusions: Training and continuous education on health insurance regulations and guidelines are necessary to minimize errors that could lead to the refusal of social insurance payments.