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20-10-2022

Healthcare services with referral: things to know

Iliustracija

Residents are already well-aware that everyone covered by the compulsory health insurance and having a referral can pick any institution for their qualified expert medical services, testing and procedures, as long as the institution has an agreement with the health insurance funds. This guarantee is often used, when the clinic they are registered with has long queues for the service they need. However, if you’re not careful enough, there is an important condition, which may lead to having to pay for a service, which could be free.

Several clients of Vilnius Territorial Health Insurance Fund (THIF) come to request for a reimbursement for expert doctor consultations, procedures, day surgeries, etc. every month. They claim to be covered by the compulsory health insurance that they applied for services with a referral. However, some of these inquirers need to be explained a couple of important things that they’ve missed: first – a reimbursed service can be provided only if the medical institution has an agreement with the health insurance funds namely for the said service, and second – the Compulsory Health Insurance Fund (CHIF) covers the services by making a payment directly to the medical institution that has provided them rather than the residents in person.

CHI-covered persons with a referral can get reimbursed services both at public and private medical institutions. However, before application, it is necessary to find out if the desired medical institution has an agreement with the health insurance funds for the specific service and the way it is provided. For example, if a referral indicates the need for a consultation with a cardiologist or an ophthalmologist, the patient may address any medical institution in Lithuania, which has an agreement with the health insurance funds for namely the services, offered by these specialising doctors. When choosing a facility, where the patient is to be provided with, for example, varicose vein surgery services, it is also important to find out, if the facility has an agreement for day surgery services (cardiovascular procedures).

A physician, issuing a referral must indicate at least three medical facilities that provide the reimbursed services needed by the patient. A detailed list of facilities that have signed agreements with the health insurance funds and specific services, is published on the health insurance funds website. According to the legislation, medical facilities must also publish a list of services that are covered by an agreement with the health insurance funds on their websites, at the reception desk and other easy-to-access locations. Patients are always recommended to contact and check this information with the chosen medical facility.

Upon picking a suitable medical facility, which really offers the needed reimbursed services, insurance-covered patients with a referral do not need to pay for the services indicated in the referral, including diagnostic and treatment measures, medicine, surgeries, anaesthesia, etc. This may not apply if patients choose to jump the queue, or receive payable, more expensive or additional services that are not reimbursed. Before making payments at medical facilities, patients must sign their agreement to pay for the services. It is necessary to read it carefully and, if needed, ask to explain what the payment is for and why.

Sometimes insurance-covered patients agree to pay, but doubt if the payment is valid, thinking that the services provided to them can probably be covered by CHIF funds. Then they contact the health insurance funds asking to reimburse the costs that they believe were unreasonable. However, the health insurance funds cannot reimburse the costs to the residents in person – the money for the services, provided under an agreement between the health insurance funds and the medical facility, is paid to the medical facility.

In case of any doubts regarding the validity of the payment for medical services, patients should firstly write a request for an explanation to the administration of the medical facility, which must give it. If a patient is unsatisfied with the explanation and the money is not repaid, the patient must send the request to the administration and the explanation received to his/her local THIF. Should it turn out that the request to pay for the services was unreasonable, the patient’s costs will be compensated by the medical facility that he or she paid for the services at.

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Information of Vilnius Territorial Health Insurance Fund

The NHIF invites you:

Your questions are welcome by email[email protected]or phone: local (8 5) 232 2222, international +370 5 232 2222

Last updated: 24-01-2023

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