Analisis Faktor Penyebab Pending Klaim Rawat Inap Akibat Koding Rekam Medis Di Rumah Sakit Umum Daerah (RSUD) Dr. Soedirman Kebumen
Abstract
The National Health Insurance (JKN) claim is the submission of patient care costs for BPJS Kesehatan participants by the hospital to BPJS Kesehatan which is carried out collectively and billed to BPJS Kesehatan every month. After that, BPJS Kesehatan will approve claims and make payments for eligible files, but for files that are not yet eligible for claim or pending (unclaimed) must be returned to the hospital for re-examination. Dr. Soedirman Kebumen Hospital is a hospital that collaborates with BPJS to provide services to patients through a financing system, where problems are still found, especially related to pending claims. The incident of claiming at Dr. SoedirmanKebumen Hospital was caused by several things including administration, medical, coding, inappropriate files and others. Based on apreliminary research, it was found that the pending claim file in September 2022 was 163 of the 1041 inpatient files using the JKN. From these problems, an analysis of the factors behind pending claims due to coding was carried out through quantitative research with a phenomenological approach. The results of the analysis shows the return of BPJS Kesehatan inpatient claim file at Dr. Soedirman Kebumen Hospital occurred due to differences in the perception of the diagnosis code in the claim file between the hospital coder and the BPJS Kesehatan verifier. In addition, the lack of supporting data as an enforcement of the diagnosis also affects the diagnosis accuracy code which results in pending claims. Based on these problems, there is a need for efforts that must be made by hospitals, such as evaluation activities related to officer performance according to existing job descriptions and improving the quality of human resources, especially coding officers by conducting training and socialization regarding policy updates regarding claims. Optimization of activities with the creation of SPO related to claims in order to minimize the occurrence of pending claims.
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