KLAIM TIDAK LAYAK BAYAR PESERTA JAMINAN KESEHATAN NASIONAL DI LAYANAN RAWAT JALAN RUMAH SAKIT JIWA PROF. DR. SOEROJO, MAGELANG
THE UNFEASIBLE PAYMENT CLAIM FACTORS OF NATIONAL HEALTH INSURANCE PARTICIPANTS IN PROF. DR. SOEROJO MAGELANG MENTAL HEALTH HOSPITAL'S OUT-PATIENT SERVICE
Abstract
Background: The hospital payment mechanism in National
Health Insurance era used INA-CBG's package tarif. The
service payment which had given by hospital was paid by
Indonesian National Health Insurance Agency with claiming
mechanism. There were several factors and causes that
affected unfeasible payment claim which could harm the
hospital.
Objective: Identify the factors that caused the unfeasible
payment claim, identify the cause of the unfeasible payment
claim, describe the attitude of doctors, the attitude of the leader
ship of the hospital, the attitude of the administration RSJS,
attitude BPJS Health Magelang and describe RSJS leadership
communication to the cause of the unfeasible payment claim in
the outpatient service RSJS.
Method: This research was an exploratory case study research
with single holistic case study design. Analysis unit in this
research was outpatient services in Prof. dr. Soerojo Magelang
Mental Health Hospital. Research informants were specialized
doctor and general practitioner RSJS, Prof. dr. Soerojo
Magelang Mental Health Hospital's leaders, Prof. dr. Soerojo
Magelang Mental Health Hospital's administrators, and
Indonesian National Health Insurance Agency branch in
Magelang City. The informant selection used purposive
sampling. Data collection used in-depth interview and
document observation. Result: The cause of unfeasible
payment claim consisted of medical services cause and
administrative cause. The cause of medical services most that
one episode of outpatient, one episode of inpatient and
diagnosis is not emergency. The data difffference between BPJS
Kesehatan and medical record, non-emergency diagnosis that
considered as emergency diagnosis, one episode of
outpatient/inpatient considered as two episodes of
outpatient/inpatient. The communication RSJS leaders about
unfeasible payment claim is not optimal, the attitude doctor's
with less information, the rules have not been clearly linked
specifificity RSJS in healthcare delivery, indifffference claim
services were they have rendered to the participant JKN,
understanding verififier BPJS about medically less in determining
the unfeasible payment claim into inconsistencies, too tight in
the verifification process and the workload verififier BPJS in RSJS
large enough can increase in unfeasible payment claim .The
attitude of the leadership of RSJS own conduct follow-up but
followup information was not communicated to the doctor RSJS,
the attitude of the administration RSJS who respond positively
to minimize the unfeasible payment claim.
Conclusion: The leaders' communication, doctor's attitude,
Indonesian National Health Insurance Agency's attitude and the
unpresented operational standard, and procedure in
determining steps of unfeasible payment claim were factors that
could enhance the incidence of unfeasible payment claim.