Guidance on the implementation of payment and settlement for health insurance medical examination and treatment costs in Vietnam

Guidance on the implementation of payment and settlement for health insurance medical examination and treatment costs in Vietnam​ (Image from the Internet)

On February 5, 2025, Vietnam Social Security issued Official Dispatch 247/BHXH-CSYT regarding the implementation of financial settlements for health insurance-based medical examination and treatment.

Guidance on the implementation of payment and settlement for health insurance medical examination and treatment costs in Vietnam

To ensure the progress of quarterly and annual settlement of health insurance costs as stipulated, Vietnam Social Security requests provincial social security agencies to conduct quarterly and annual settlements as follows:

* Quarterly and Annual Financial Settlement with Health Insurance-Certified Medical Facilities

** Quarterly Data Finalization

- No later than the 15th day of the first month of the succeeding quarter (15/4, 15/7, 15/10, 15/01 of the following year), provincial or district social security agencies where the contract is signed (generally referred to as the social security agency) must finalize the data from the previous quarter with the medical facility to ensure data consistency between Form C79-HD and data on the health insurance verification information system. The finalization record must affirm that the facility has sent complete data, with no outstanding records and no request for payment of expenses from the previous quarter (if any).

The health insurance-certified medical facility is legally responsible for the medical expenses claimed, used for patients, and consistent with records and case histories at the facility as well as data on the health insurance verification information system. Medications, chemicals, supplies, and medical equipment must be procured in compliance with relevant laws on bidding; medical services are paid according to payment eligibility and service pricing regulations.

- Health insurance costs for individuals under the temporary management of the Politburo, Secretariat shall be submitted in paper format as per Clause 3, Article 10 of Circular 30/2020/TT-BYT dated December 31, 2020, by the Ministry of Health. Ensure settlement transparency concerning copying, receiving, storing, and providing state secret materials as prescribed in Law on Protection of State Secrets and Decree 26/2020/ND-CP.

** Quarterly and Cumulative Annual Settlement

- Within 30 days from the receipt of quarterly financial settlement reports from a medical facility for quarters I, II, III, and within 60 days for quarter IV, the provincial social security agency must complete health insurance verification work and notify the medical facility of verification results, settlement amounts, average increase in costs warned but not adjusted, and excess above projected annual expenditure (if any).

- By the 15th day of the second month of the subsequent quarters after I, II, III (15/5, 15/8, 15/11), the provincial social security agency must complete the settlement for quarters I, II, III with the medical facility; by March 15 of the following year for quarter IV.

- Quarterly settlements with the medical facility are conducted based on verified health insurance expenses and within the funding limits notified by the provincial social security agency to the medical facility (including initially projected and adjusted expenses). The funding will decrease gradually through each quarterly settlement.

Example: Total funding available at Medical Facility A is 6 billion VND (initial projection of 5 billion VND, supplemented in quarter IV by 1 billion VND). Verifiable health insurance costs incurred quarterly: quarter I is 1 billion VND, quarter II is 2 billion VND, quarter III is 2 billion VND, quarter IV is 2 billion VND.

The funding on Form C82-HD is reflected as follows: quarter I is updated in code 6, Form C82-HD as 6 billion VND; for quarters II, III, the software auto-updates code 5a, Form C82-HD respectively as 5 billion VND, 3 billion VND; in quarter IV, updates code 5a, Form C82-HD as 1 billion VND and code 7, Form C82-HD as 1 billion VND. The total cumulative annual settlement is 6 billion VND, with 1 billion VND not yet settled.

- Note: Cross-regional expenses are settled according to the verification results from the Multi-line Verification Center for Health Insurance and Payment.

- For the Quarter IV 2024 Settlement, provincial social security agency directors are required to lead a meticulous verification and settlement within funding limits for the health insurance-certified medical facilities to be completed by February 25, 2025. For amounts exceeding projections for 2024, the provincial social security agency completes settlement with the medical facility. Vietnam Social Security will guide on reviewing and determining excess costs payable after receiving responses from the Ministry of Health to Official Dispatch 4294/BHXH-CSYT dated November 22, 2024, from Vietnam Social Security on continuing to request guidance on issues in implementing certain regulations in Decree 75/2023/ND-CP (second time).

** Organization of Financial Settlement for Health Insurance Medical Expenses

Quarterly, based on the health insurance verification results, the social security agency notifies the quarterly verification results, creates Forms C80-HD and C82-HD (signed and sealed) to the medical facilities via post. Within 3 working days from receipt, the medical facility verifies, signs Form C82-HD, and issues financial invoices for submission by post to the social security agency as a basis for payment.

* Settlement of Medical Expenses Incurred in the Previous Year

Expenses from the previous year are settled upon notification from Vietnam Social Security (comprehensively settled with the medical facility in the nearest quarter), ensuring the cumulative annual total does not exceed the amount notified by Vietnam Social Security.

* Comprehensive Annual Financial Settlement of Health Insurance Medical Expenses

** Thorough Review of Annual Health Insurance Medical Expenses at Medical Facilities:

Based on the data and relevant documentation, provincial social security agencies are responsible for conducting reviews on various topics guided by Vietnam Social Security and locally developed topics; to examine and reject any unqualified payment expenses, expenses not recognized, and refused payments as per inspection and audit conclusions (if available) at all health insurance-certified medical facilities locally.

For expenses surpassed beyond the projected costs, expenses reduced after quarter IV settlement, the provincial social security agency consolidates into assessment and appraisal forms for health insurance medical expense settlements. If a medical facility needs to recover or receives additional payments, it is carried into the following year’s quarter.

** Supplemental Funding for Exceeding Projected Medical Expenses

Provincial social security agencies base the direct payments, primary health care expenses settled, and incurred health insurance medical expenses within projected figures, excess projections, and propose supplemental payments at medical facilities to reconcile funds for health insurance medical expenses under the province's allocated budget.

** Annual Settlement Report Timeline

For 2024, by February 28, 2025, provincial social security agencies report annual health insurance medical expense settlements per Form 01 accompanying this Official Dispatch and generate evaluation and appraisal forms as guided in Decision 1753/QD-BHXH (digitally signed on centralized appraisal software) and submit signed, sealed paper documents to Vietnam Social Security, specifically:

- Consolidate direct payment expenses for patients per amounts recorded by the Planning and Finance Department as settled.

- Consolidate primary health care transfer expenses as per recorded settled amounts by the Planning and Finance Department.

- Consolidate annual and previous year's supplementary health insurance medical expenses per settled amounts for quarter IV and cumulative year; supplemental finance for exceeding projected expenses within the provincial agency's budget allocation.

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