However, the current health insurance payment mechanism contains several inconsistencies that do not align with the operational realities of medical facilities, necessitating prompt solutions.

Early morning at the Thanh Hải General Clinic already sees a large number of people registering for check-ups, predominantly using health insurance. Lò Thị Phong, a resident of team 4 in Thanh Yên commune who requires quarterly check-ups for a chronic condition, expressed her satisfaction with the streamlined registration and professional guidance she received, noting that her medication was provided strictly according to insurance regulations.

Since its inception, the Thanh Hải General Clinic has focused on a patient-centric model, investing in modern machinery such as MRI, CT scanners, and digital X-rays, equipment typically found only at provincial or central levels. This synchronized investment, including automated biochemical and hematological testing systems, allows patients to access high-quality diagnostics locally, saving significant time and travel costs. In 2025 alone, the clinic performed over 60,000 examinations, with 56,595 of those being health insurance-related visits, illustrating the increasing trust the public places in private facilities.

Despite these advancements, Mai Thị Thảo, the Director of the clinic, pointed out that the health insurance payment mechanism remains inconsistent with the reality of private medical operations. One major hurdle involves the application of legal regulations regarding a doctor’s scope of practice. For instance, specialists in fields like dentistry who perform general examinations face payment rejections because their reissued practice certificates only list a specific specialty, leading to conflicting interpretations between medical facilities and insurance agencies. This specific issue left VND 727.9 million in services unpaid at several units in 2025.

Another significant obstacle concerns inpatient bed payments. While Circular No.22/2023/TT-BYT stipulates that payments should be calculated quarterly based on capacity, local inspections often apply a daily or departmental calculation. Consequently, if a department exceeds its planned bed count on a specific day, those extra services go unpaid even if the overall hospital capacity for the quarter remains within limits. This discrepancy alone resulted in VND 4.88 billion in unpaid costs throughout 2024 and 2025.

Furthermore, exceeding health insurance budget estimates is placing immense pressure on medical facilities, with unresolved costs from 2023 to 2024 reaching VND 13.9 billion. This surge is primarily driven by an increase in outpatient and inpatient visits, rising service prices under new circulars, and the upgrading of several units from Level III to Level II hospitals.

Moving forward, medical facilities are urging central ministries and authorities to amend Decree No.96/2023/NĐ-CP to ensure that bed occupancy exceeding 10% of the licensed capacity is still reimbursed at an appropriate rate, thereby protecting the rights of both the facilities and the insured patients. There is also an urgent need for unified guidelines regarding the scope of practice for specialized doctors and temporary instructions for pending costs to prevent long-term financial stagnation that hinders medical operations.