SOME FACTORS AFFECTING THE REFUSAL OF PAYMENT FOR HEALTH INSURANCE MEDICAL EXAMINATION AND TREATMENT COSTS AT 19-8 HOSPITAL 2023-2024

Objective: To analyze some positive and negative factors that affect the refusal of payment for medical examination and treatment costs covered by health insurance by the Hanoi Social Security agency at 19-8 Hospital for the period 2023–2024. Research method:  Cross-sectional research design, using qualitative research information based on 07 in-depth interviews and 01 group discussion according to a set of pre-designed questions for subjects directly involved in the management and implementation of payment and settlement of health insurance medical examination and treatment costs at the  19-8 Hospital in 2023 and 2024. Results and recommendations: Research shows that reducing health insurance payment refusals achieved positive results thanks to expanded payment policies, support from the Social Insurance agency, close direction from hospital leaders and the application of information technology and error warnings. However, there are still problems due to the incomplete legal framework and technical process, the information technology system lacks specialized human resources, uneven assessment capacity, and the management of health insurance and medical records at departments/rooms has not been focused. However, there were still some negative factors including: legal regulations that changed quickly without enough detailed guidance, some technical procedures not yet issued by the Ministry of Health, pressure to standardize data, uneven capacity among appraisers, department/office leaders and doctors not paying enough attention to health insurance management, incomplete medical records and IT system that did not meet requirements because of a lack of specialized staff. Therefore, the study recommends that 19-8 Hospital should establish a special health insurance network early, increase continuous training, standardize instruction documents and operating procedures, control medical records and invest in upgrading the HIS software with smart warning functions and standardize treatment protocols to reduce mistakes and limit the costs that are refused.