Exploring Payment Refusals for Health Insurance-Covered Medical Costs: A Hospital Case Study in Vietnam

Abstract

Adjudication and rejection of payment for healthcare costs covered by health insurance pose challenges in maintaining healthcare operations and ensuring the rights of patients and healthcare staff at hospitals. Research on this issue is limited globally and in Vietnam. This study was conducted to understand the current status of refusal to pay medical examinations and treatment costs covered by health insurance at a hospital in Can Tho, Vietnam, and to explore the reasons for payment refusal. A cross-sectional descriptive study retrieved data on health insurance-covered medical expenses that were refused at a hospital in Can Tho, Vietnam, over three years from January 1, 2020, to December 31, 2022. This study found that from 2020 to 2022, the number of settlements was consistently lower than the proposed costs. The highest refused payment amount in 2022 was 334,232,049 Vietnamese dong (0.4%). Inpatient health insurance-covered medical expenses faced greater payment refusal than outpatient expenses. Medications, surgical procedures, and bed charges were the top three reasons for payment refusal from 2020 to 2022. The primary cause of payment refusal remains predominantly associated with medication costs. This poses challenges in cost management and necessitates measures to address the issue of payment refusal within the health insurance system.