PENGEMBALIAN BERKAS KLAIM PASIEN PESERTA JAMINAN KESEHATAN NASIONAL (JKN) DI RSUD SULTAN SYARIF MOHAMAD ALKADRIE KOTA PONTIANAK
CLAIM PENDING OF NATIONAL HEALTH INSURANCE PROGRAM MEMBERS IN SULTAN SYARIF MOHAMAD ALKADRIE HOSPITAL, PONTIANAK
Abstract
Background: Approach of managed care in the National Health
Insurance Program (JKN) puts hospitals as a health facility referral with the prospective payment system. Treatment of patients
should be done and handled in primary health facilities. Although
the number of patient referral to hospitals in JKN era remains high.
The impact of the hospital is faced with an increase in claims bills
to BPJS Kesehatan. By 2016 in RSUD Pontianak it was noted that
6.98% of the income came from JKN hospital patients which had not
been paid by BPJS Kesehatan, so some were returned. A research
needs to be conducted on the cause of the returned claim file from
BPJS Kesehatan verifier to RSUD Pontianak.
Objective: To find out the cause of the claims pending in RSUD
Pontianak.
Methods: The research is an exploratory case study with a single
case study design approach.
Results: The claim process at RSUD Pontianak is still not as good
as never completed every month. Most of the causes of returned
claims are administrative errors and medical reasons. Maladmin
istration in the form of typing errors, dates, but a sign from the
doctor. Medical reasons include coding disagreements, differences
in perceptions about specific inspection directions, lack of support,
differences in perceptions about secondary diagnostic inputs. Performance coding is limited to differences in perceptions between
Coder and BPJS Kesehatan Verifier, positive physician response
to file claims reversed, BPJS Kesehatan Verifier perceptions are
constrained in capacity, differences in educational background, differences in understanding with Coder on Reselected Coding, and
differences in regulatory implementation in the claims process.
Conclusion: Technical error of claims administration process, difference of perception of coding, difference of comprehension about
complementary examination, special treatment and secondary diagnosis input, and difference of perception to JKN regulation on verifier of cause of claim file of JKN patients return to RSUD Pontianak.
Copyright (c) 2019 Andi Sulaimana, Andreasta Meliala, Julita Hendrartini
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