Reimbursement procedure for RSA drugs has been disclosed

other types are 3 months

The NHIS completes payment of ₩5.46 billion with 16,024 cases in 5 years

Nam-seon Choi, "request pharmaceutical companies to provide information to hospitals and clinics for patients to check"

The amount of risk-sharing refunds paid to patients by The NHIS for the last five years under the Risk Sharing Agreement (RSA) contract reached ₩5.46 billion.

 

More than half of them, or ₩3 billion, were paid out from January to September of this year.

 

Nam-seon Choi, head of the NHIS drug price negotiation department, recently revealed the procedure for paying the patient's co-payment difference at a risk-sharing drug price negotiation system and online information session for follow-up management for more than 100 pharmaceutical companies.

 

RSA is a system in which pharmaceutical companies partially bear the risks of the efficacy and effects of new drugs or the financial impact of insurance, and pharmaceutical companies must set collateral to the NHIS according to the refund rate.

 

"After monitoring the RSA drug claim data, the refund amount will be determined and notified according to the contract details with each pharmaceutical company," he said.

 

"If the pharmacecutical company does not pay to the NHIS within one month, the security right will be exercised after the last notification." When notifying the refund amount = The NHIS monitors the billing data every one year due to the setting of the estimated billing cap for Expenditure Cap among RSA targets.

 

The monitoring cycle is one year, but the final notification will be after '1 year + 6 months' as the exact amount of reimbursement can be known only after The HIRA's review of the request for treatment at a medical institution is completed and The NHIS' payment of medical care benefits is completed.

 

For example, if a drug is listed in January 2020, after monitoring the treatment from January to December of that year, a notification of the refund amount will be made to the pharmaceutical company around June 2021.

 

“Other claims are monitored every six months and additional claims are notified.” He said, "In Expenditure Cap, the cap setting is based on the treatment start date, so the monitoring can be notified only when the billing data and the actual payment is accumulated based on the treatment start date." For types other than Expenditure Cap, the amount of refund is notified after 2 months after monitoring of the payments paid every 3 months.

 

If it is paid from January to March, the notice will be made in May.

 

He explained, "The NHIS calculates the refund amount for the billed amount, excluding the total amount of copayment, the share of other agencies, and the HIRA's review and adjustments among the requested data for medical institutions." The difference in part of the patient's copayment =How will the actual amount of reimbursement for patients who use RSA drugs will be determined?

 

In the case of anticancer drugs subject to RSA, the listed price is ₩1 million, and the refund rate is 30%.

 

Patients receive a copayment of 5% at the time of treatment and pay ₩50,000 as a drug fee.

 

Choi said, "The NHIS receives a refund of ₩300,000 from a pharmaceutical company, and patients pay ₩35,000, 5% of the actual price of ₩700,000." He also said, "If the refund amount is notified to the pharmaceutical company and the calculation of the refund amount for the previous year's co-payment limit system is completed, based on the completed claim, ₩15,000 will be refunded." However, in order to prevent overlapping support, if the copayment cap refund is larger, the RSA drug refund will not be received.

 

Patients taking positive listed drugs are paid the difference every quarterly four times a year.

 

In this way, the NHIS paid the patient's co-payment difference, which increased ₩220 million from 1,020 cases in 2016 and to 1.08 billion, 4,194 cases in 2019.

 

In particular, by September this year, 5,984 cases, amounting to ₩3.4 billion, were paid.

 

Choi said, "There was an increase in RSA drugs, and as the number of patients with Refund type increased, nearly 6,000 cases were already refunded this year." He added, "It is expected to increase by one thousand by the end of the year." Reimbursement of the difference for patients by themselves in full =In a form in which the pharmaceutical company directly refunds the patient, the pharmaceutical company must notify the NHIS of the payment details monthly.

 

The NHIS compares the reimbursement details of the pharmaceutical company with the full amount of the claims and sends a notice to the person concerned.

 

If the medical staff determines and administers it as the subject of full self-payment, it can also be checked with a statement of medical expenses, receipts, and prescriptions as a refund target.

 

Choi said, "We need to cooperate with pharmaceutical companies so that patients who pay the entire amount will know that the difference will be refunded." "It is easy for patients to receive reimbursement if they need to be in advance.

 

It is necessary to provide guidance and guides in medical institutions."