Problematic BPJS health patient pending claims in the implementation of INA-CBGS and management handling
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Published:
Nov 9, 2023
Keywords:
BPJS Health, INA-CBGs, Pending claims
Section
Informtion System
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Abstract
Guarantee program health (BPJS Health ) does payment to facility health reference level continued (FKRTL) in Indonesian Case Base Groups (INA-CBGs). BPJS health claim is submission cost maintenance patient participant guarantee health national (JKN) by parties House Sick to BPJS health carried out _ in a way collective and billable every the month . Currently _ Still happen problem between BPJS Health and Advanced Level Referral Health Facilities (FKRTL) including the relevant Bima City Hospital with problem coding that doesn't appropriate , medical resumes are not complete , incomplete relevant between medical resumes with results inspection support medical , and errors entry claim . Research objectives This is For know in a way deep regarding : (1) System planning management claim ; (2) System organizing ; (3) Implementation management record medical and files condition claim ; (4) System supervision in management JKN claim . Study This use approach studies case . Research results : (1) SPM recording has not been implemented medical ; (2) The hospital's internal coders and verifiers are not yet available equipped knowledge knowledge INA-CBGs coding , internal verification still underway done manually because _ Not yet There is application internal verification ; (3) Implementation management record medical and files condition claim Not yet in accordance with PMK number 26 of 2021 and BA agreement together guide management solution problem INA-CBGs claims in 2020; (4) System supervision in management JKN claim yet held optimally.
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Sulastri, S., Menap, M. and Sastrawan, S. (2023) “Problematic BPJS health patient pending claims in the implementation of INA-CBGS and management handling”, Jurnal Mantik, 7(3), pp. 1967-1976. doi: 10.35335/mantik.v7i3.4278.
References
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Peraturan Menteri Kesehatan Nomor 82 Tentang Sistem Informasi Manajemen Rumah Sakit, (2013).
Peraturan Menteri Kesehatan Nomor 26 Tentang Pedoman Indonesian Case Base Groups (INA-CBGs) Dalam Pelaksanaan Jaminan Kesehatan, (2021).
Lee, K. M. K., Page, A., Kim, S., Al-Diery, T., Koeper, I., Singh, I., Hawthorne, D., & Johnson, J. (2023). Perceptions and expectations of health professionals regarding hospital pharmacy services and the roles of hospital pharmacists: A qualitative systematic review and meta-synthesis. Exploratory Research in Clinical and Social Pharmacy, 10, 100264. https://doi.org/10.1016/j.rcsop.2023.100264
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Nurhadianah, N. (2022). Analisis Pending dan Dispute Klaim Kementerian Kesehatan Pasien Rawat Inap Covid 19. Dohara Publisher Open Access Journal (DPOAJ).
Ode, W., Wunari, D., Karimuna, S. R., & Munandar, S. (2016). Studi Penerapan Sistem Pembayaran Layanan Kesehatan dengan Sistem Diagnosis Penyakit (Indonesia Case Based Groups/Ina-cbgs) di Ruang Rawat Inap Rumah Sakit Umum Bahteramas Kota Kendari Tahun 2015. Doctoral dissertation, Haluoleo University.
Pamularsih, R. A. (2015). Penyelenggaraan Pelayanan Kesehatan Melalui BPJS Di Rumah Sakit. Universitas Islam Indonesia.
Sakidjan, I. (2014). Analisis Kelengkapan Catatan Rekam Medis Kasus Tetralogy of Fallot pada Implementasi INA-CBGS di RSPJN Harapan Kita. Jurnal Administrasi Rumah Sakit Indonesia, 1(1).
Santiasih, W. A., Simanjorang, A., & Satria, B. (2021). Analisis Penyebab Klaim pending BPJS kesehatan Rawat Inap di RSUD DR.RM. Djoelham Binjai. Jurnal Of Healthcare Technology Ang Medicine.
Sitorus, M. I., Yulia, N., Fannya, P., & Rumana, N. A. (2022). Tinjauan peranan koder dalam pengajuan berkas klaim BPJS Kesehatan pasien rawat inap di RSUD DR. RM Djoelham Kota Binjai. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda, 7(1), 56-64.
Widodo, P. P. (2023). Klaim Pending Rawat Inap Bpjs Kesehatan Di Rs X. Prosiding Seminar Nasional Rekam Medis & Manajemen Informasi Kesehatan.
Windari, A., & Kristijono, A. (2016). Analisis Ketepatan Koding Yang Dihasilkan Koder Di RSUD Ungaran. Jurnal Riset Kesehatan, 5(1), 35–39.
Yin, R. K. (2021). Studi Kasus Desain & Metode (8th ed.). PT. Rajagrafindo Persada.
Yusuf, Z., Nurwanah, A., & Sari, R. (2022). Fraud pada Program Jaminan Kesehatan Nasional Perpekstif: Kompetensi Auditor Internal dengan Pendekatan Fenomenologi. Owner:
Afful-Dadzie, E., & Egala, S. B. (2022). Medical practitioners’ decision making on quality of online medical information: A consumption values theory analysis. Health Policy and Technology, 11(4), 100685. https://doi.org/10.1016/j.hlpt.2022.100685
Albano, D., Follman, S., Patel, Y. D., Gantotti, S., Reilly, P., & Hermes-DeSantis, E. R. (2021). Enhancing Patient Care: Value of Pharmaceutical Medical Information Services. The Journal for Nurse Practitioners, 17(7), 840–845. https://doi.org/10.1016/j.nurpra.2021.01.009
Andrikov, D. A., & Kuchin, A. S. (2021). Development of a prototype of a medical information system for a clinical diagnostic center. Procedia Computer Science, 186, 287–292. https://doi.org/10.1016/j.procs.2021.04.147
Ardhitya, T., & Perry, A. (2015). Faktor Yang Melatarbelakangi Penolakan Klaim BPJS Oleh Verifikator BPJS di RSJD Amino Gondohutomo Provinsi Jawa Tengah. Udinus Repository.
BPJS. (2021). BPJS kesehatan Dorong RS Ajukan Berkas Klaim Covid secara Lengkap, Berita Umum BPJS kesehatan, 13 Oktober 2021. https://www.bpjs-kesehatan.go.id/bpjs/post/categories/MjI/berita.
Cresweel, J. W. (2012). Research Design: Pendekatan Kuantitatif, Kualitatif dan Mixed. Pustaka Pelajar.
Gedikci Ondogan, A., Sargin, M., & Canoz, K. (2023). Use of electronic medical records in the digital healthcare system and its role in communication and medical information sharing among healthcare professionals. Informatics in Medicine Unlocked, 42, 101373. https://doi.org/10.1016/j.imu.2023.101373
Hu, F., Huang, M., Sun, J., Zhang, X., & Liu, J. (2021). An analysis model of diagnosis and treatment for COVID-19 pandemic based on medical information fusion. Information Fusion, 73, 11–21. https://doi.org/10.1016/j.inffus.2021.02.016
Indawati, L. (2019). Analisis akurasi koding pada pengembalian klaim BPJS rawat inap di RSUP Fatmawati tahun 2016. Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), 113–113.
Jaswa, E. G., Lindquist, K. J., Hariton, E., Aliaga, K. E., Cedars, M. I., & Huddleston, H. G. (2023). Association between social media use for medical information during pregnancy and likelihood of vaccination against COVID-19. AJOG Global Reports, 3(4), 100262. https://doi.org/10.1016/j.xagr.2023.100262
Keat-Chuan Ng, C., Linus-Lojikip, S., Mohamed, K., & HSS, A.-S. (2023). Application of medical information system to identify dengue outbreak factors: Insights from a hyperendemic city in Malaysia. International Journal of Medical Informatics, 177, 105162. https://doi.org/10.1016/j.ijmedinf.2023.105162
Peraturan Menteri Kesehatan Nomor 82 Tentang Sistem Informasi Manajemen Rumah Sakit, (2013).
Peraturan Menteri Kesehatan Nomor 26 Tentang Pedoman Indonesian Case Base Groups (INA-CBGs) Dalam Pelaksanaan Jaminan Kesehatan, (2021).
Lee, K. M. K., Page, A., Kim, S., Al-Diery, T., Koeper, I., Singh, I., Hawthorne, D., & Johnson, J. (2023). Perceptions and expectations of health professionals regarding hospital pharmacy services and the roles of hospital pharmacists: A qualitative systematic review and meta-synthesis. Exploratory Research in Clinical and Social Pharmacy, 10, 100264. https://doi.org/10.1016/j.rcsop.2023.100264
Lim, R. B. L., Yeat, C. L., Vighneshvaran, R., Kasinathan, N., Ahmad Subki, S. Z., Singh, A. H. S., & Saad, N. D. (2023). Mapping Levels of Palliative Care Service Development in Malaysian Public Hospitals Using the WHO Public Health Model of Palliative Care. Journal of Pain and Symptom Management, 66(3), 221–229. https://doi.org/10.1016/j.jpainsymman.2023.05.017
Madan Kumar, C., Amin, R., & Brindha, M. (2023). Cryptanalysis of Secure ECC-Based Three Factor Mutual Authentication Protocol for Telecare Medical Information System. Cyber Security and Applications, 1, 100013. https://doi.org/10.1016/j.csa.2023.100013
Maryati, W., Yuliani, N., & Justika, A. I. (2022). Karakteristik Rumah Sakit dan Keakuratan Kode Diagnosis Mempengaruhi Hasil Klaim INA-CBGs. LINK, 16(2), 141–148.
Nuraini, N., Wijayanti, R. A., Putri, F., Alfiansyah, G., Deharja, A., & M.W., S. (2019). Optimalisasi Manajemen Pengajuan Klaim Pending Pasien BPJS Rawat Inap di RS Citra Husada Jember. Jurnal Kesmas Indonesia.
Nurhadianah, N. (2022). Analisis Pending dan Dispute Klaim Kementerian Kesehatan Pasien Rawat Inap Covid 19. Dohara Publisher Open Access Journal (DPOAJ).
Ode, W., Wunari, D., Karimuna, S. R., & Munandar, S. (2016). Studi Penerapan Sistem Pembayaran Layanan Kesehatan dengan Sistem Diagnosis Penyakit (Indonesia Case Based Groups/Ina-cbgs) di Ruang Rawat Inap Rumah Sakit Umum Bahteramas Kota Kendari Tahun 2015. Doctoral dissertation, Haluoleo University.
Pamularsih, R. A. (2015). Penyelenggaraan Pelayanan Kesehatan Melalui BPJS Di Rumah Sakit. Universitas Islam Indonesia.
Sakidjan, I. (2014). Analisis Kelengkapan Catatan Rekam Medis Kasus Tetralogy of Fallot pada Implementasi INA-CBGS di RSPJN Harapan Kita. Jurnal Administrasi Rumah Sakit Indonesia, 1(1).
Santiasih, W. A., Simanjorang, A., & Satria, B. (2021). Analisis Penyebab Klaim pending BPJS kesehatan Rawat Inap di RSUD DR.RM. Djoelham Binjai. Jurnal Of Healthcare Technology Ang Medicine.
Sitorus, M. I., Yulia, N., Fannya, P., & Rumana, N. A. (2022). Tinjauan peranan koder dalam pengajuan berkas klaim BPJS Kesehatan pasien rawat inap di RSUD DR. RM Djoelham Kota Binjai. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda, 7(1), 56-64.
Widodo, P. P. (2023). Klaim Pending Rawat Inap Bpjs Kesehatan Di Rs X. Prosiding Seminar Nasional Rekam Medis & Manajemen Informasi Kesehatan.
Windari, A., & Kristijono, A. (2016). Analisis Ketepatan Koding Yang Dihasilkan Koder Di RSUD Ungaran. Jurnal Riset Kesehatan, 5(1), 35–39.
Yin, R. K. (2021). Studi Kasus Desain & Metode (8th ed.). PT. Rajagrafindo Persada.
Yusuf, Z., Nurwanah, A., & Sari, R. (2022). Fraud pada Program Jaminan Kesehatan Nasional Perpekstif: Kompetensi Auditor Internal dengan Pendekatan Fenomenologi. Owner:
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