Quyết định 466/QD-BHXH

DECISION

ISSUING THE PROCESS OF HEALTH INSURANCE INSPECTION

GENERAL DIRECTOR OF VIETNAM SOCIAL INSURANCE

Pursuant to the Law on Health Insurance No. 25/2008/QH12 dated November 14, 2008;

Pursuant to Decree No. 94/2008/ND-CP dated August 22, 2008 of the Government defining the functions, tasks, powers and organizational structure of the Vietnam Social Insurance;

Pursuant to Decree No. 62/2009/ND-CP dated July 27, 2009 of the Government stipulating in detail and guiding the implementation of a number of articles of the Law on Health Insurance;

Pursuant to the Joint Circular No. 09/2009/TTLT-BYT-BTC dated August 14, 2009 of the Inter Ministries of Health and Finance guiding the implementation of health insurance;

Pursuant to Decision No. 82/QĐ-BHXH dated January 20, 2010 of the General Director of Vietnam Social Insurance issuing the Regulation on organization of implementation of medical examination and treatment, management and use of health insurance;

After having the opinion from the Ministry of Finance in the official Dispatch No. 1914/BTC-HCSN dated February 14, 2011 and the opinion from the Ministry of Health in the official Dispatch No. 1709/BYT-BH dated April 01, 2011;

At the proposal of the Head of Committee of Health Insurance Policy;

DECIDES:

Article 1. Issued with this Decision is the Process of health insurance inspection;

Article 2. This Decision takes effect from the date of its signing. The previous regulations in contradiction with this Decision are annulled;

Article 3. Chief of Office of Vietnam Social Insurance, the Head of Committee of Health Insurance Policy, the Head of units directly attached to the Vietnam Social Insurance, Director of Social Insurance of provinces and centrally-affiliated cities, Director of Social Insurance: Ministry of Defense, People’s Police, Government Cipher Committee and organizations and units having contract of medical examination and treatment with health insurance with the social insurance agency are liable to execute this Decision./.

PROCESS

HEALTH INSURANCE INSPECTION
(Issued together with Decision No. 466/QD-BHXH dated April 19, 2011 of the General Director of Vietnam Social Insurance)

Chapter 1.

PROCESS OF HEALTH INSURANCE INSPECTION AT MEDICAL EXAMINATION AND TREATMENT FACILITY

Article 1. Checking the procedures for medical examination and treatment with health insurance

The health insurance inspector shall coordinate with the employees of medical examination and treatment facility to check the procedures for medical examination and treatment with health insurance as follows:

1. At the patient receiving area:

1.1. Checking health insurance card or substitute paper of health insurance card:

a) Checking the card form to ensure the health insurance card is issued by the social insurance agency; the card is intact, not torn, erased or corrected;

b) Comparing the photo (with seal) stuck on personal papers with valid photo including: ID card, Passport, driver’s license, Party member card, Union member card, pension card, student card, public servant card, official card with the patient to ensure the card is consistent with the patient;

c) Checking the information on the health insurance card: issue date and value of card use, name, age, gender of patient, code of card, code of medical examination and treatment in accordance with the regulations of Vietnam Social Insurance;

d) Checking and comparing the birth certificate or certificate of live birth or certificate of communal People’s Committee to ensure the legality and consistency with the subject as children under 6 years old who can use the above papers to replace the health care card upon medical examination and treatment. The health insurance inspector shall guide the child’s parents or guardian to contact the responsible agency (communal People’s Committee, district-level social Insurance) to complete the procedures for issue of health insurance card to the children under 06 years old under regulations of law;

1.2. Checking the hospital transfer paper and other substitute papers of the hospital transfer paper (re-examination appointment, temporary residence registration, business trip paper or decision on study appointment):

a) Checking the form and contents specified on the hospital transfer paper to ensure the proper form as prescribed by the Ministry of Health, not being torn, erased or corrected; the seal and signature of the legal representative of the medical examination and treatment facility where the patient is transferred are in accordance with the hospital rules issued by the Ministry of Health. Comparing the information on the hospital transfer paper with the health insurance card and other papers (if any) of the patient. Checking and determining the date of hospital transfer to be consistent with the date of hospital admission;

b) Making comparison with the provisions on transfer of technical professional line as provided for in the Circular No. 10/2009/TT-BYT dated August 14, 2009 of the Ministry of Health to determine the reasonableness of transfer of technical professional line and ensure the legitimate interests of patient having the health insurance card;

c) Checking the reasonableness of the re-examination appointment, temporary residence registration or business trip paper if the patient uses the above papers in lieu of the hospital transfer paper;

1.3. Determining the conditions and the level of social insurance entitlement on the following cases:

a) Patients are indicated to use the anti-rejection drug and cancer drug outside the list;

b) Patients voluntarily participating in health insurance are indicated to use high-tech services with great costs;

c) Cases of medical examination and treatment of improper technical professional line as provided for by the Ministry of Health;

2. At the inpatient area:

2.1. Performing the periodic or irregular inspection at departments or wards to carry out the following contents:

a) Checking and comparing a number of patients named in the drug allocation book of Departments or wards with the actual number of patient being treated in the wards;

b) Performing the random selection to check the implementation of procedures for medical examination and treatment with the health insurance including: checking and determining the initial place for medical examination and treatment; referral of hospital transfer or the emergency situation of the patient is recorded in the medical record, time of hospital admission; comparing the personal papers with valid photo with the records of medical officer in the administrative part of medical record;

2.2. Checking the procedures for health examination with health insurance in the medical record for discharged patients including:

a) Comparing the information on the medical record with the List of expenses of medical examination and treatment: full name, age, address, health insurance card number, value of card use, diagnosis, diagnosis code...

b) Checking and comparing the referral of hospital transfer with the information recorded on the medical record;

c) Checking and determining the legality and completeness of the signatures on the medical record and on the List of expenses of medical examination and treatment to ensure the legality and reasonableness of vouchers of payment of expenses of medical examination and treatment with the health insurance in accordance with the regulations of the Ministry of Health and the Ministry of Finance;

3. Settling and handling the cases of violation of procedures for medical examination and treatment with health insurance:

3.1. Recording and revoking the health insurance card and the hospital transfer paper in the following cases:

a) Using fake health insurance card and hospital transfer paper or the health insurance card is not issued by the social insurance agency;

b) Using health insurance card whose information is erased or intentionally corrected;

c) Using the hospital transfer paper which is not issued by the transferring medical examination and treatment facility;

For the cases specified at this Point 3.1, the social insurance agency receiving the patients is responsible for recovering the amount paid (If any) at the same time inform the medical examination and treatment facility (patient transferring facility), unit or local authority managing these patients and the social insurance agency issuing the health insurance card to request and coordinate with the competent authority to handle the violation under regulations of law;

3.2. Recording and temporarily impounding the health insurance card and the hospital transfer paper in the following cases:

a) Using the health insurance card of another person for medical examination and treatment;

b) The patient is discharged from hospital but fails to get back the health insurance card, the social insurance agency shall coordinate with the medical examination and treatment facility to inspect and verify the reasons why the patient does not get back his/her card and request the competent authority to handle this case under regulations of law;

c) Failing to use the proper form of hospital transfer paper as prescribed by the Ministry of Health. For this case, upon determining the fault which does not belong to the patient, the inspector shall temporarily accept this paper to settle the interests of health insurance for the patient for that time of medical examination and treatment and make a report to the social insurance agency in order to inform the medical examination and treatment facility where the patient is transferred and request the competent authority to handle the case under regulations of law for that medical examination and treatment facility;

Article 2. Inspection of list and price of technical services, drug and medical supplies

1. Inspection of list of technical services:

a) Checking the technical services being done at the medical examination and treatment facility and comparing them with the list of those allowed to be done at that facility and approved by the competent authority in accordance with regulations to determine the legality of technical services being done;

b) Checking the list of technical services beyond the technical professional line done by the medical examination and treatment facility, comparing it with the regulations of the Ministry of Health on the procedures, process of formulation and the authority to approve the list of technical services beyond the technical professional line mentioned above;

c) Checking the name, classifying the procedure and surgery of technical services that the medical examination and treatment facility has put a part of hospital expense in the Section C2.7 of the price bracket issued with the Joint Circular No. 03/2006/TTLT-BYT-BTC-BLDTBXH dated January 26, 2006 of the Inter Ministries of Health, Finance and Labour, Invalids and Social Affairs; comparing it with regulations or process of formulation, authority to approve the list of technical services of the competent authority to determine the legality and reasonableness of the list of formulated by the medical examination and treatment facility;

d) Verifying documentation, technical process and issue authority for the new technical services that are not names in the list of technical services issued by the competent authority;

2. Inspection of price of technical services:

a) On the basis of the list of technical services that have been checked or compared at Point 1.1, Clause 1 of this Article, the health insurance inspector shall check and compare it with the price bracket of technical services as stipulated by the competent authority, check the price structure of technical services in section C2.7 mentioned above and the new technical services as prescribed by the Ministry of Health to determine the suitability of the price of technical services with the social and economic conditions, the average income of locality as well as the affordability of the health insurance fund. In case of finding the unreasonableness, the health insurance agency shall make a report to the authority having the authority to approve the modified or adjusted price as prescribed, at the same time make a report to the Vietnam Social Insurance. Pending the approval for the modified or adjusted price as prescribed by the competent authority, the expenses of these technical services are paid under the guidance of the Vietnam Social Insurance;

b) The inspection of list and price of technical services at the medical examination and treatment is done in the first month of year and when the medical examination and treatment facility supplements or changes its list of technical services or price of hospital expense and at the same time makes a comparison with the list and payment price under the regulations of health insurance on the statistics software of medical examination and treatment at the health insurance agency and the medical examination and treatment facility (if any);

3. Inspection of list of drug and medical supplies:

a) Checking and reviewing the list of drug used at the medical examination and treatment facility and comparing it with the list of treating drug mainly used at the medical examination and treatment facilities issued by the Ministry of Health and regulations on classification of technical professional line of the medical examination and treatment facility;

b) Checking the list and norm of use of radioactive drug and labeled compound used at the medical examination and treatment facility (if any), comparing them with the current regulations on radioactive safety as prescribed by the competent authority;

c) Checking and inspecting the list of medical supplies used at the medical examination and treatment facility and comparing it with the regulations on the use of these medical supplies corresponding to the list of technical services within the professional scope of the medical examination and treatment facility;

d) Checking the bidding process to provide drugs and medical supplies at the medical examination and treatment facility;

4. Inspection of price of drug and medical supplies:

a) Checking invoices of drug and medical supplies of the medical examination and treatment facility and comparing them with the bid-winning price approved by the competent authority;

b) Choosing some types of drug and medical supplies to compare them with the price published on the website of the Vietnam Social Insurance.

c) Periodically at the beginning of each quarter, choosing a number of Lists of expenses of medical examination and treatment to compare the price of drug and medical supplies with the result of in the list inspected at item a and b of this point and the data related to the medical examination and treatment with the health insurance in the computer of the medical examination and treatment facility (if any);

d) Inspector shall inform the medical examination and treatment facility of the result of inspection of list and the price of technical services, drugs and medical supplies to uniformly determine the payment scope under regulations of health insurance and make a report to the social insurance agency simultaneously;

Article 3. Inspection of expenses of medical examination and treatment with health insurance

1. Inspection of costs of outpatient medical examination and treatment:

1.1. Inspection of expense of drug and medical supplies:

a) Checking the amount, type of drug on the prescription and the patient’s signature on the prescription; making comparison with the amount of type of drug the patient actually receives;

b) Checking and comparing the amount, type and the price of drug and medical supplies specified in the List of expenses of medical examination and treatment with the type and price of list checked in Clause 3 and 4, Article 2 and the management data in the computer;

c) Checking and comparing a number of types of medical supplies on the invoices and the medical supplies actually used for patients through the product stamps sticked on the payment documentation to determine that the patient has used the proper type of medical supplies indicated by the medical examination and treatment facility;

1.2. Inspection of costs of technical services:

a) Checking and comparing the indication of procedures, testing, sub-clinical, diagnostic imaging techniques…(especially the cases of using high-tech services with costs), making a comparison with the patient’s condition to determine the reasonableness of indication of these technical services;

b) Comparing the price of technical services on the List of expenses of medical examination and treatment with the list and price of technical services applied at the medical examination and treatment facility and approved by the competent authority with the management data in computer;

1.3. Upon detection of cases of abuse in drug allocation and receipt, use of testing, improper calculation of prescribed price:

Inspector shall record the case and make a record to the leadership of the medical examination and treatment facility and the social insurance agency to uniformly resolve it or request the competent authority to handle it under regulation of law;

1.4. Summary of number of patients coming for medical examination and treatment and number of technical services done:

a) At the end of working day, based on the statistical data of hospital (in the computer, admission book), the inspector shall record the number of patient with health insurance coming to hospital for health examination, admission, discharge or transfer in a day; the number of type of technical services performed for patients (cases of overtime examination of inspector are calculated in the following working day). Periodically at the end of day, week, month and quarter, making a comparison and closing the number of outpatients, amount and types of technical services, drug, medical supplies…for the payment and finalization;

b) Finding and learning the cause of abnormal changes in the number of patients coming for medical examination and treatment; the number of technical services indicated for performance, the non-matching general statistical number of the medical examination and treatment facility…and informing the medical examination and treatment facility of these to take remedial measures and making a report to the leadership of the social insurance agency;

1.5. Evaluation of reasonableness, safety and effectiveness in outpatient medical examination and treatment:

Based on the guidelines for treatment and drug use issued by the Ministry of Health; professional regulation, technical process and list of drug used at the medical examination and treatment facility to evaluate the reasonableness, safety and effectiveness in the medical examination and treatment according to a number of contents as follows:

a) Analyzing and evaluating the reasonableness and appropriateness between the diagnosis with the technical services indicated on the type, amount and effectiveness for the treating process; making a comparison with the medical examination and treatment facility with health insurance equivalent to the technical professional line;

b) Evaluating the reasonableness, safety and effectiveness in drug indication: type, amount of drug in a prescription, combination of drug used for patients (drug indicated in accordance with diagnosis, age, gender, combination of drug exactly as directed).

c) Determining and analyzing the rate and structure of drug (foreign or domestic drug); structure of drug expense, testing, diagnostic imaging…in the total expense of outpatient medical examination and treatment;

d) For the health stations of communes or equivalent: requesting the provision of list of medical officers qualified for health examination and prescription to ensure the quality of medical examination and treatment as a basis for determining the legality of the patients’ prescriptions;

dd) In case of detection of unreasonableness between the diagnosis and testing indication and prescription in treatment: the inspector shall record (photocopying the prescription) and talk with the treating doctor to reach an agreement on the remedy. In case of failure of agreement, the inspector shall make a report to the leadership of the medical examination and treatment facility and the social insurance agency;

1.6. Inspection on the statistic data of payment of expenses of medical examination and treatment

a) Every month/quarter, the inspector shall receive the list for payment of expenses of outpatient medical examination and treatment with signatures with the electronic data file as prescribed; use the statistic software of medical examination and treatment for performance of inspection;

b) Inspecting and comparing the number of patient required to pay the expenses of medical examination and treatment in the period by the medical examination and treatment facility including: patient initially registered, multi medical line patient, improper medical line patient; making a comparison with the result of summary by month;

c) Checking the amount of drug and the technical services that have been used for patients, making a comparison with the books of the medical examination and treatment facility (drug allocation book, technical services performance book…);

d) At the beginning of each quarter, the inspector shall compare the result of inspection of of expenses of drug and technical services of the previous quarter with the summary table of use of drug and technical services in medical examination and treatment and the data provided by the hospital to determine the expenses of drug and technical services that are paid and finalized in the period;

dd) Using the function of inspection support of the statistical software of expenses of medical examination and treatment to detect the following cases:

- The patient has his/her health examined many times in a day, month and quarter; splitting the expenses of medical examination and treatment of one time into many files; making payment of expenses of medical examination and treatment in 01 time of outpatient medical examination and treatment;

- Borrowing the health insurance card or doing fraudulent statistics of expenses of medical examination and treatment; incorrect statistic data: code of subject, code of interest, code of health insurance card, expenses, initial code of medical examination and treatment, diagnosis code…

- Unreasonable indications of testing, procedure and drug are not in accordance with the diagnosis and treatment;

- Cases with expenses which are great, unusual or are used most.

For the above-mentioned cases, the inspector shall check all payment files again (List of expenses of medical examination and treatment, prescription, drug allocation book, testing book, procedure…), refuse the payment of cases of wrong statistics, abuse of health insurance or failure to fully provide information as prescribed;

e) Deliberately choosing (according to diagnosis, type of technical services, departments or room of health examination) or randomly a number of cases for comparison with the List of expenses of health care cost and payment data.

g) Reaching an agreement with the medical examination and treatment facility in the forms and transferring them to the social insurance agency as a basis for assessment, summary and finalization;

2. Inspection of expenses of inpatient treatment:

2.1. Inspection of expenses before patient’s discharge:

a) Checking and comparing the amount, types of drug or medical supplies between the medical record, book of receipt and allocation of drug of departments and treating wards with the actual amount used by the patients; making a comparison with the list of drug of the hospital to find the cases where the patients must allocate by themselves the drugs named in the list;

b) Checking and comparing the amount and types of technical services indicated and performed (based on the result sticked in the medical record and through giving direct questions to the patients). For the diagnostic imaging techniques (with images printed as prescribed), carrying out additional checking of whether or not the images are included in the medical records;

For each time of checking, the inspector shall make a record based on the contents checked with the certification of medical officer and representative of head of treating departments;

2.2. Inspection of expenses after the patient’s discharge:

a) Comparing the medical record with the List of expenses of medical examination and treatment, drug allocation book, slip of publicity of expenses of drugs and medical supplies including: amount, type of technical services, drug, perfusion fluid, blood…, number of days, type of  hospital bed;

b) Comparing the expenses between the List of expenses of medical examination and treatment and the list that has been checked in Clause 3 and 4 of this Process;

c) Determining the same level of payment of expenses of medical examination and treatment of the patient based on the subjects insured, medical examination and treatment with proper or improper medical line; code of interest recorded on the health insurance card and other papers (certificate of merit, certificate of insurance participation for 3 consecutive years), making a comparison with the level of expense determined by the medical examination and treatment facility;

2.3. Inspection and evaluation of unreasonableness in diagnosis and treatment:

Based on the guidelines for treatment and use of drug issued by the Ministry of Health; professional regulation, technical process, list of drugs and medical supplies used at the medical examination and treatment facility to evaluate the reasonableness and quality of inpatient treatment based on the following basic contents:

a) Diagnosis is consistent with symptoms described in medical record and ICD-10 diagnostic codes; statistics of right / wrong rate between diagnosis upon hospital admission and and hospital discharge; listing causes for the patients’ hospital transfer.

b) Indication of sub-clinical testing is in accordance with the diagnosis, the number of time of reasonable performance according to the treatment requirement;

c) Use of drug: type, dosage, route of administration, time of use for patient (suitable with diagnosis, age, gender…) and degree of development of treatment process;

d) Performance of professional regulation:

- The time when the patient is done with tests and treated from the hospital admission and the time to the surgery from the hospital admission

- Performing the regulation on consultation in diagnosis, treatment and use for a number of drugs (marked with *) as prescribed;

- Performing the regulations on health examination, drug allocation, nursing, daily care… especially for the patients with serious illness and cases of surgery;

Where the unreasonableness in diagnosis and treatment or professional mistake, the inspector shall talk with the treating doctor to reach an agreement on remedial measures. In case of failure, the inspector shall make a report to the leadership of the medical examination and treatment facility and the social insurance agency;

2.4. Inspection on the statistical data of payment of expenses of inpatient treatment:

a) Every month/quarter, the inspector shall receive the list for payment of expenses of inpatient treatment with signatures with the electronic data file as prescribed; use the statistic software of medical examination and treatment for performance of inspection;

b) Inspecting and comparing the number of patient required to pay the expenses of medical examination and treatment in the period by the medical examination and treatment facility including: patient initially registered, multi medical line patient, improper medical line patient; making a comparison with the result of summary by month;

c) Checking and inspecting the amount of drug and technical services used for the patients, making a comparison with the books of the medical examination and treatment facility (drug allocation book, technical services performance book);

d) At the beginning of subsequent quarter, the inspector shall compare the result of drug inspection of the previous quarter with the statistic table of impatient drug sue or checking or making a comparison with the report on import, export, inventory and use of drug with health insurance in the period. In unbalanced case, the inspector shall request the medical examination and treatment facility to give explanation;

Making a comparison of inspection of technical services in the period with the statistic table of use of impatient technical services and the amount requested for payment of drug and technical services with the amount requested for payment on the table of general expenses of impatient treatment and the data provided by the medical examination and treatment facility;

dd) Using the function of inspection support of the statistical software of expenses of medical examination and treatment to detect the following cases:

- The patient receives inpatient treatment many times in a month and quarter; splitting the expenses of medical examination and treatment into many files for payment;

- Borrowing the health insurance card; incorrect statistic data: code of subject, code of interest, code of health insurance card, expenses, initial code of medical examination and treatment, diagnosis code, expenses, treating day…

- Payment statistics is coincident with the courses of inpatient treatment and coincident with the time of courses of inpatient and outpatient treatment;

- Unreasonable indications of testing, procedure and drug are not in accordance with the diagnosis and treatment;

- Cases with expenses which are great, unusual or are used most.

For the above cases, the inspector shall re-check all payment files (List of expenses of medical examination and treatment, medical record, drug allocation book, technical services performance book); refuse to make payment in cases of wrong statistics, abuse of health insurance or failure to fully provide information as prescribed;

e) Deliberately choosing (according to diagnosis, type of technical services, departments or room of health examination) or randomly a number of cases for comparison with the List of expenses of health care cost and payment data.

g) Reaching an agreement with the medical examination and treatment facility in the forms and transferring them to the social insurance agency as a basis for assessment, summary and finalization;

2.5. Inspect done at the residence or the patient’s place of work:

In case of necessity, the social insurance agency shall carry out the verification at the patient’s residence or place of work: choosing the cases of signs of abuse as follows: wrong subjects participating in the health insurance, irrational drug use, false or forged signature of patient…in the List of expenses of medical examination and treatment to conduct the verification at the patient’s residence or place of work (making a comparison with the employee timesheet and payment table of social insurance…) to determine the authentication of the patient’s medical examination and treatment and use of medical services and receipt of payment under the regulation of health insurance;

3. Inspection of file for direct payment

3.1. Inspection of procedures for medical examination and treatment:

Comparing the files of direct payment and health examination book/medical record to check the implementation of procedures for medical examination and treatment with health insurance including:

a) Examination date, hospital and discharge date;

b) Condition of patient upon medical examination and treatment (emergency/ no emergency);

c) Performance of procedures for medical examination and treatment with health insurance;

d) Summary of information and comparison with current regulation to determine the patient goes to have his/her health examined or treated with proper or improper medical line;

dd) Determination of reason for non entitlement or insufficient entitlement to the benefits of health insurance;

3.2. Inspection of expenses of medical examination and treatment with health insurance:

a) Comparing the amount, type of drug and medical supplies, testing, technical services in the invoices and documents of the patient with the medical record and the price list of drug, medical supplies and technical supplies of the medical examination and treatment facility;

b) Determining the expenses of medical examination and treatment under the benefits of health insurance to which the patients are not entitled at the medical examination and treatment facility;

c) Summarizing the result of inspection under the form specified by the Vietnam social insurance to be sent to the social insurance agency;

Article 4. Advising and publicizing the legal policies on health insurance and settlement of difficulties and problems in medical examination and treatment with the health insurance

1. For the medical examination and treatment facility with the health insurance: Periodically or when there are new problems arising in relation to the implementation of policies on health insurance, the inspector shall come into contact with the leadership of the medical examination and treatment facility to perform the following contents:

a) Promptly publicizing the new policies and regulations on health insurance; the implementation of medical examination and treatment with the health insurance at the medical examination and treatment facility; summarizing and reflecting these difficulties and problems and proposing the solving measures in the briefings of the medical examination and treatment facility;

b) Organizing professional training and techniques of general statistics of expenses of medical examination and treatment with health insurance for the medical officers upon the request of the medical examination and treatment facility;

c) Providing information on rights and responsibilities of the persons participating in the health insurance and regulations on the procedures for medical examination and treatment with the health insurance at the medical examination and treatment facility;

d) Receiving and settling the difficulties and problems under the authority in the implementation of medical examination and treatment with the health insurance; promptly making a report to the superior on the existing problems which the medical examination and treatment facilities have requested to solve them but beyond the authority;

2. For the patients with health insurance card: The inspector shall:

a) Receive, advise and settle the difficulties and problems under his/her authority concerning the procedures and interests of medical examination and treatment with the health insurance;

b) Every week/month, organize talks with the patients or their relatives at departments or treating rooms to propagating, explaining and give guidelines for the regulations on the medical examination and treatment with the health insurance;

Chapter 2.

PROCESS OF HEALTH INSURANCE INSPECTION AT THE SOCIAL INSURANCE AGENCY

Article 5. Process of assessment and signing of contract of medical examination and treatment with the health insurance

1. The provincial social insurance shall coordinate with the Health Service to survey and make a list of the medical examination and treatment facilities in the area eligible for signing of contract of medical examination and treatment with the health insurance as follows:

a) Public medical examination and treatment facility:

- Technical professional line (Central government, province, district and commune);

- Hospital grade under the decision of the competent authority (special grade, grade 1, 2, 3, 4 and no grade);

b) Non- public medical examination and treatment facility:

Equivalent to the technical professional line and grade of hospital with the public medical examination and treatment facility:

c) Qualified medical examination and treatment facility is the place of initial registration for medical examination and treatment;

d) Medical examination and treatment facility with the health insurance of line 2;

For the medical examination and treatment facilities which sign contract for the first time or have the time of suspending the contract from 6 months or more, the social insurance agency shall inform and instruct these medical examination and treatment facilities to send documents accompanied with file for signing contract of medical examination and treatment with the health insurance as prescribed;

2. Assessment of file for signing contract of medical examination and treatment with the health insurance:

a) Checking the file of contract of medical examination and treatment with the health insurance of the medical examination and treatment facilities that signed in the previous year, notifying and requiring the medical examination and treatment facility to supplement the file as prescribed;

b) Receiving and checking the files for signing contract of medical examination and treatment facilities that initially signs the contract or has suspended the contract from 06 months or more. Notifying the medical examination and treatment facility to supplement or complete the files under regulations;

c) Summarizing the result of file assessment and giving opinions to the leadership of provincial social insurance;

3. Direct survey and inspection at the medical examination and treatment facilities:

a) Making a list of facilities to be inspected before signing contract of medical examination and treatment and sending a written request to the Service of Health for coordinated inspection;

b) Conducting the inspection under the contents specified by the Vietnam social insurance and certifying the summary of the medical examination and treatment facility;

c) Summarizing the result of inspection and making a list of medical examination and treatment facility eligible for signing contract of medical examination and treatment with the health insurance;

4. Agreement with Service of Health on the following basic contents:

a) Regulation on transfer of technical professional line in medical examination and treatment with the health insurance for the medical examination and treatment facilities within province or city.

b) Regulation on transfer of technical professional line for a number of medical examination and treatment facilities in bordering areas in province and between provinces;

c) Regulation on group of subjects and a number of persons participating in health insurance registered for initial medical examination and treatment at the medical examination and treatment facilities at provincial, central or equivalent medical line as stipulated;

5. Draft contract of medical examination and treatment with the health insurance:

a) Exchanging and reaching an agreement with the medical examination and treatment facilities on the method of payment and additional provisions in accordance with the type of contract and the medical examination and treatment facility in order to draft the contract of medical examination and treatment with the health insurance as stipulated;

b) Sending the draft contract to the medical examination and treatment facility to reach an agreement with the contents and complete the draft contract.

6. Signing of contract of medical examination and treatment with the health insurance and report to Vietnam social insurance as stipulated

Article 6. Statistics, summary and implementation of regulation on information and report:

1. Making and managing list of medical examination and treatment facilities with the health insurance

a) On the basis of list of medical examination and treatment facilities with the health insurance (file dm_benhvien.dbf), the provincial social insurance shall summarize, review, complete and update information on categorization of hospital, technical professional line, method of payment, type of contract, code of medical examination and treatment facility assigned to sign contract the medical examination and treatment facilities with the health insurance at communal line;

b) Registering the code of medical examination and treatment facilities with the health insurance having just signed contract for addition into the list of medical examination and treatment facilities with the health insurance and the statistical software of expenses of medical examination and treatment

2. Identification of number of registration card of initial medical examination and treatment; medical examination and treatment fund and payment ceiling of treatment expenses of medical line 2:

a) At the beginning of each quarter, based on the number of card, health insurance premium of previous quarter, the social insurance agency shall announce the number of health insurance card, the fund of medical examination and treatment with the health insurance temporarily used at the medical examination and treatment facility;

Before finalization, the social insurance agency shall officially inform the medical examination and treatment facility of the number of health insurance card for initial registration of medical examination and treatment, the fund of medical examination and treatment with the health insurance to be used in quarters;

b) Based on the expenses of medical examination and treatment with the health insurance in the previous year at the medical examination and treatment facility, the social insurance agency shall determine the capitation fee/ceiling expense of treatment of medical line 2 under the guidelines of Vietnam social insurance; make announcement so that the medical examination and treatment with the health insurance may know the method of determination and anticipate the fund of medical examination and treatment with the health insurance based on the fixed portion before signing of contract;

3. Statistics and summary of data for payment, finalization and report:

a) Receiving the statistical and summary data of the medical examination and treatment facilities with the health insurance including: List for payment of expenses of inpatient and outpatient and the accompanied data files;

b) Checking the contents on the forms, signatures and seals as stipulated;

c) Comparing the statistical forms of expenses of medical examination and treatment with the health insurance made by the medical examination and treatment facility with the electronic data;

d) Making a summary form of payment and finalization of expenses of medical examination and treatment with the health insurance with the medical examination and treatment facility;

dd) Making a form of list of expenses of medical multi line medical examination and treatment outside province to make a report to the social insurance of provinces and Vietnam social insurance;

e) Making statistics of expenses directly paid under the form specified by Vietnam social insurance;

g) Every quarter, making a report to the Vietnam social insurance on the list of patients having a course of treatment from 50 million dong or more;

h) Using statistical and summary software to make forms of report under regulations of Vietnam social insurance;

Article 7. Process of direct payment of expenses of medical examination and treatment with the health insurance

1. Receiving and verifying files for direct payment:

a) Checking the legality of files for payment, signing the copies for certification (health insurance card, hospital discharge permit, other papers excluding invoices);

b) Instructing the patient to supplement the file as stipulated. Refusing to receive files and giving the explanation to the subjects about the cases not subject to the scope of payment of health insurance funds;

c) Instructing the patients to fully fill in the slip for direct payment of expenses of medical examination and treatment with the health insurance;

d) Giving the patient the note for payment;

2. Inspection of file for direct payment:

a) For files that can be settled immediately without inspection at the medical examination and treatment facility: collection and inspection of files for submission to the leadership for approving the payment to the patient;

b) For files that must be inspected at the medical examination and treatment facility: preparing slip for inspection to be sent to the inspection division at the medical examination and treatment facility in the province or social insurance of province or city where the patients come to have their health checked;

Receiving the result of inspection, checking and comparing it with the inspection request and requesting the additional inspection if the result of response is not satisfactory;

3. Determination and submission the rate of direct payment for approval:

a) Summarizing the result of inspection and proposing the rate of payment and preparing the summary of direct payment of medical examination and treatment with the health insurance;

b) Transferring the summary to the Financial and Planning Department for checking the contents of expenses as requested by the Health insurance inspection Department;

c) Submitting for approval from the leadership the rate of payment for expenses of medical examination and treatment to the persons having health insurance card;

d) Carrying out the payment to the persons having health insurance card and record it in the general monitoring book and keeping files of direct payment as stipulated;

Chapter 3.

IMPLEMENTATION ORGANIZATION

Article 8. Arranging and assignment of health insurance inspector

Director of provincial social insurance shall, based on the number, qualification of inspector and actual situation at localities to arrange the inspector at the medical examination and treatment facility as follows:

1. At the health station at communal level or equivalent and the general clinics of area having no permanent inspector but the periodical or irregular inspection must be done, particularly focusing on the following contents:

a) A number of patient coming to have their health examined every day and month;

b) Health examination, prescription and drug allocation;

c) Book recording and statistical report;

d) Anticipation of drug and medical supplies consumed;

dd) Utilization of fund of medical examination and treatment with the health insurance at the communal health station;

2. At the specialized medical examination and treatment facilities: Arranging permanent inspector at least 02 days in a week;

3. At the general hospitals: Each hospital is arranged with at least 01 permanent inspector;

3.1. General hospital at district level or equivalent: Fully carrying out the contents of the process of health insurance inspection at the medical examination and treatment facility in 02 areas:

a) Receiving and policy consultation area: arranging inspector with intermediate or higher qualification under regulations on professional skills of Vietnam social insurance;

b) Professional inspection area: arranging inspector with college qualification under regulations on professional skills of Vietnam social insurance;

3.2. General hospital at provincial level or equivalent: arranging inspector as specified at Point 3.1 mentioned above, forming professional inspection group with qualification of medicine or pharmacy university with experience and thorough understanding of inspection skills to carry out the inspection of expenses of medical examination and treatment with the health insurance;

4. For the facilities that apply the method of payment with services fees: arranging inspector to perform the following:

a) Checking a number of patients coming to have their health examined or being admitted;

b) Supervising the amount of drug and technical services allocated to patients;

c) Checking and determining the proper allocation of drug and technical servies;

d) Inspecting and evaluating the reasonableness of indications of diagnosis and treatment with the health insurance;

5. For the facilities that apply the method payment by capitation: arranging inspector to focus on work in order to ensure the patients’ interests and manage the capitation fund as follows:

a) Supervising the quality of medical examination and treatment to ensure the intests of patients who have health insurance card;

b) Monitoring the transfer of technical professional line; detecting the cases of causing difficulties or failure of settlement for the patients to receive the transfer of medical line although the health examination and treatment facility is not qualified for examination and treatment;

c) Supervising the utilization of fund of medical examination and treatment and promptly informing the health examination and treatment facility of unusual development on the expenses of medical examination and treatment;

6. For the facilities that apply the method payment by disease case (or group of diagnosis): arranging inspector to focus on work as follows:

a) Inspector records the diagnosis code for payment of expenses of medical examination with the health insurance;

b) Identifying causes of failure to include the payment for the cases with diagnosis of diseases specified in the contract;

c) Evaluating the quality of medical examination and treatment under professional process: detecting cases that do not comply with the professional process; informing the medical examination and treatment facility and reporting to the social insurance agency;

Article 9. Implementation of process of health insurance inspection

1. At the medical examination and treatment facility

1.1. For the medical examination and treatment facility with permanent inspector:

a) The Head of health insurance inspection department shall instruct the inspectors to prepare the plan and working contents by day, week and month, time of completion and result of implementation;

b) Based on the number of permanent inspector and characteristics of the medical examination and treatment facility, the Head of health insurance inspection department shall assign work in accordance with the ability and professional qualification of inspectors;

1.2. For the medical examination and treatment facility with the health insurance without sufficient permanent inspectors in days of week:

a) Inspector shall develop plan for permanence at the medical examination and treatment facilities assigned while instructing the medical officers to perform the contents of process of health insurance inspection during the time without permanent inspector;

b) Performing irregular inspection and summarizing the result of inspection at the medical examination and treatment facility;

c) Performing the monthly or quarterly inspection of statistic forms as a basis for payment and finalization of expenses of medical examination and treatment with the health insurance;

1.3. For the facilities without permanent inspectors:

a) The social insurance agency shall instruct the medical officer to perform the contents of process of health insurance inspection. Preparing the plan for periodic or irregular inspection by month and quarter;

b) Every month and quarter, performing the inspection of statistic forms as a basis for finalization. Paying attention to the comparison with the times of inspection at the medical examination and treatment facility;

2. At the social insurance agency:

2.1. For provincial social insurance

a) Assessing the files for signing contract of medical examination and treatment and drafting contract: arranging inspector with university degree to check the files for signing of contract and performing direct inspection at the medical examination and treatment facility; drafting contract and submitting it to the leadership for signing with the medical examination and treatment facility;

b) Direct payment:

- Arranging inspector at the one-stop division to receive and check the files and instruct the patients to complete the procedures as stipulated;

- The inspection Department shall arrange officer in charge to perform the professional skills under the process of direct payment specified in Clause 2; point a and c, Clause 3, Article 7 of this Process;

- The Financial and Planning Department shall arrange officers to perform the professional skills specified at Point b, Clause 3, Article 7 of this Process;

c) General statistics: The health insurance inspection Department shall arrange officer to perform the general statistics under the provisions in Article 6 of this Process;

2.2. For districtric-level social insurance:

a) Assessing and drafting contract of medical examination and treatment with the health insurance: arranging officer to coordinate with the provincial social insurance to perform the contents specified in Clauses 2, 3, 5, 6, Article 5 of this Process;

b) Direct payment:

- The one-stop division shall receive the files and instruct the patients to complete the prescribed procedures and transfer them to the inspection division. The district-level shall arrange an inspector cum reviewer of files of direct payment

- For the files which do not need an inspection at the medical examination and treatment facility but inspection must be done directly on the files which shall be submitted to the leadership for approval;

- For the files which need an inspection at the medical examination and treatment facility outside district area, they shall be collected and sent to the health insurance department under the provisions at Point b, Clause 2, Article 7 of this Process;

- Director of district social insurance shall approve the rate of direct payment as decentralized;

c) Statistics and summary: arranging officer to perform statistic work and summarize the expenses of medical examination and treatment with the health insurance under the provisions at Point a, Clause 2 and 3 (except for Point dd), Article 6 of this Process and transferring data to the provincial health insurance;

Article 10. Responsibility of social insurance of provinces and centrally-affiliated cities and the units

1. The Head of health insurance policy performance Committee shall coordinate with the units concerned to instruct and inspect the implementation of Process of health insurance inspection of social insurance of provinces;

2. Director of research and information Center shall supplement and complete the statistical software of expenses of medical examination and treatment in accordance with the Process of health insurance inspection;

3. The Heads of units concerned with functions and tasks assigned are liable to conduct the implementation of this Process;

4. Director of social insurance of provinces shall make a decision on the decentralized implementation of Process of health insurance inspection for district-level social insurance./.