PENGEMBALIAN BERKAS KLAIM PASIEN PESERTA JAMINAN KESEHATAN NASIONAL (JKN) DI RSUD SULTAN SYARIF MOHAMAD ALKADRIE KOTA 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.