Factors Causing Pending Claims at Nyi Ageng Serang Regional General Hospital
DOI:
https://doi.org/10.18196/jmmr.v12i3.80Keywords:
Pending Claims, Social Health Insurance Administration Body, National Health InsuranceAbstract
Nyi Ageng Serang Regional General Hospital submits monthly collective claims for the Social Health Insurance Administration Body patients. Based on the observations made at the Nyi Ageng Serang Regional General Hospital, the Social Health Insurance Administration Body claim file was pending by the Social Health Insurance Administration Body verifier because it needed to be confirmed. The pending claims will cause the payment of claims from the Social Health Insurance Administration Body to the hospital to be delayed, and it might affect service activities and financing for the hospital. Pending claims must be explored more deeply to the causal factors so they can be handled appropriately. This study aims to describe the factors causing pending claims for the Social Health Insurance Administration Body at the Nyi Ageng Serang Regional General Hospital. Data collection techniques used observation techniques, documentation studies, and interviews. Data analysis was performed using descriptive analysis. External factors that have caused pending claims include discrepancies in claim rates with the Minister of Health Regulations, incorrect codes, and incomplete codes. Meanwhile, the internal factors causing pending claims, according to the 5M management element, were the Man, Material, and Method factors.
References
Afrriani, F., Noor, A. Y., & Sugeng. (2022). Analisis Penyebab Pending Dan Tidak Layak Berkas Klaim Rawat Jalan Jaminan Kesehatan Nasional (JKN) Di RSKIA Sadewa Yogyakarta Tahun 2022. Jurnal Permata Indonesia, 13(November), 107–115. https://doi.org/10.59737/jpi.v13i2.169
Agiwahyuanto, F., Anjani, S., & Juwita, A. (2021). Tinjauan Penyebab Pengembalian Berkas Klaim Kasus Gawat Darurat. Jurnal Manajemen Informasi Kesehatan Indonesia, 9(2), 113–125. https://doi.org/10.33560/jmiki.v9i2.318
Ardinata, M. (2020). Tanggung Jawab Negara terhadap Jaminan Kesehatan dalam Perspektif Hak Asasi Manusia (HAM) (State Responsibilities Of Health Guarantee In The Perspective Of Human Rights). Jurnal HAM, 11(2), 319–333. https://doi.org/10.30641/ham.2020.11.319-332
Fitriani, Y., & Hidayat, B. (2023). Evaluation of Pending Claims Bakti Timah Karimun Hospital in Assessing the Effectiveness of the V-Claim Application. Journal of Social Research, 2(4), 1100–1105. https://doi.org/10.55324/josr.v2i4.781
Heltiani, N., Asroni, N., & Suryani, T. E. (2023). Analisis Ketepatan Kode Diagnosa Obstetri Terhadap Kelancaran Klaim BPJS RS.X Kota Bengkulu. 9(1), 1–11.
Kurnia, E. K., & Mahdalena. (2022). Faktor Penyebab Pending Klaim BPJS Kesehatan Pasien Rawat Inap di Rumah Sakit X Periode Triwulan 1 Tahun 2022. Prosiding Seminar Informasi Kesehatan Nasional (SIKesNas), 173–177. Retrieved from https://ojs.udb.ac.id/index.php/sikenas/article/view/1741
Kusumawati, A. N., & Pujiyanto. (2018a). Analisis Kinerja Dokter Verifikator Internal dalam Menurunkan Angka Klaim Pending di RSUD Koja Tahun 2018. Jurnal ARSI, 6(1), 1–10. https://doi.org/10.7454/arsi.v6i1.3244
Kusumawati, A. N., & Pujiyanto. (2018b). Faktor-Faktor Penyebab Pending Klaim Rawat Inap di RSUD Koja tahun 2018. Cdk-282, 47(1), 25–28. Retrieved from https://cdkjournal.com/index.php/CDK/article/view/7
Latifah, M., & Putri, A. S. (2021). Trend Pending Claim Rawat Jalan Bpjs Kesehatan RS. Panti Wilasa, Dr. Cipto Semarang. Jurnal Ilmiah Penelitian Kesehatan, 1(1), 18–24.
Leonard, D. (2016). Pengorganisasian Klaim Pelayanan Pasien JKN di RSUP dr. M. Djamil Padang. Menara Ilmu, 10(1), 168–177. Retrieved from https://jurnal.umsb.ac.id/index.php/menarailmu/article/view/34/17
Librianti, Rumenengan, G., & Hutapea, F. (2019). Analisa Pengisian Rekam Medis Dalam Rangka Proses Kelengkapan Klaim BPJS Di RSUD dr. Chasbullah Abdulmadjid Kota Bekasi 2018. Jurnal Bidang Ilmu Kesehatan, 9(1), 50–61. Retrieved from http://ejournal.urindo.ac.id/index.php/kesehatan/article/view/344
Listyorini, P. I., & Ramadhan, N. A. (2022). Analysis of Pending Claims Due to Incompatibility of Diagnostic and Action Codes in Inpatients in Hospitals. Proceeding of International Conference on Science, Health, And Technology, 393–400. https://doi.org/10.47701/icohetech.v3i1.2257
Maulida, E. S., & Djunawan, A. (2022). Analisis Penyebab Pending Claim Berkas BPJS Kesehatan Pelayanan Rawat Inap Rumah Sakit Universitas Airlangga. Media Kesehatan Masyarakat Indonesia, 21(6), 374–379. https://doi.org/10.14710/mkmi.21.6.374-379
Mudiono, D. R. P., Deharja, A., Selviyanti, E., & Alamanda, W. (2023). Analysis of Individual Characteristics of Employee's Performance at Regional Hospital Dr. Soebandi Jember on the Case of BPJS Inpatient Pending Claim. Jurnal Aisyah : Jurnal Ilmu Kesehatan, 8(1), 315–322. https://doi.org/10.30604/jika.v8i1.1533
Nabila, S. F., Santi, M. W., & Deharja, A. (2020). Analisis Faktor Penyebab Pending Klaim Akibat Koding Berkas Rekam Medis Pasien Rawat Inap di RSUPN Dr. Cipto Mangunkusumo. J-REMI : Jurnal Rekam Medik Dan Informasi Kesehatan, 1(4), 519–528. https://doi.org/10.25047/j-remi.v1i4.2157
Nurdiah, R. S., & Iman, A. T. (2016). Analisis Penyebab Unclaimed Berkas Bpjs Rawat Inap Di Rsud Dr. Soekardjo Tasikmalaya. Jurnal Manajemen Informasi Kesehatan Indonesia, 4(1), 23–28. https://doi.org/10.33560/.v4i2.128
Oktamianiza, Yulia, Y., Putri, K. A., Rahmadhani, & Aditiya. (2022). Faktor Penyebab Pending Klaim Pada Pasien Rawat Inap Di RSUD dr. Rasidin Padang Tahun 2022. Jurnal Kesehatan Lentera ’Aisyiyah, 5(2), 635–638. https://doi.org/10.31983/jrmik.v5i1.8397
Peraturan Menteri Kesehatan Republik Indonesia Nomor 6 Tahun 2022 tentang Penggunaan Jasa Pelayanan Kesehatan dan Dukungan Biaya Operasional Pelayanan Kesehatan dalam Pemanfaatan Dana Kapitasi Jaminan Kesehatan Nasional pada Fasilitas Kesehatan Tingkat Pe. (n.d.). Kementerian Kesehatan RI.
Peraturan Presiden Republik Indonesia Nomor 82 Tahun 2018 Tentang Jaminan Kesehatan.
Pratama, A., Fauzi, H., Indira, Z. N., & Adi, P. P. (2023). Analisis Faktor Penyebab Pending Klaim Rawat Inap Akibat Koding Rekam Medis Di Rumah Sakit Umum Daerah (RSUD) Dr. Soedirman Kebumen. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda (JIPIKI), 8(1), 124–134. https://doi.org/10.52943/jipiki.v8i1.1225
Puspaningsih, M., Suryawati, C., & Arso, S. P. (2022). Evaluasi Administrasi Klaim BPJS Kesehatan Dalam Menurunkan Klaim Pending. Syntax Literate: Jurnal Ilmiah Indonesia, 7(6), 7055–7064.
Ramadhani, S. N. (2020). Analisis Faktor Yang Mempengaruhi Kinerja Petugas Koder Dalam Proses Coding Ina-Cbg’s Rawat Inap Di Rumah Sakit Umum Haji Surabaya. Universitas Airlangga.
Rohman, H., Wintolo, A., & Susilowati, E. (2021). Analisis Penundaan Pembayaran Klaim Pada Sistem Vedika Badan Penyelenggara Jaminan Sosial Kesehatan Di Rumah Sakit Nur Hidayah Yogyakarta. Jurnal Wiyata, 8, 72–83. Retrieved from https://ojs.iik.ac.id/index.php/wiyata/article/view/254
Sahir, L., & Wijayanti, R. A. (2022). Faktor Penyebab Pending Claim Ranap Jkn Dengan Fishbone Diagram Di Rsup Dr Kariadi. Jurnal Manajemen Informasi Kesehatan Indonesia, 10(2), 190. https://doi.org/10.33560/jmiki.v10i2.480
Santiasih, W. A., Simanjorang, A., & Satria, B. (2021). Analisis Penyebab Pending Klaim Bpjs Kesehatan Rawat Inap di RSUD Dr. RM Djoelham Binjai. Journal of Healthcare Technology and Medicine, 7(2), 1381–1394.
Sitorus, M. S., Hasibuan, P. M., Erlindai, Christy, J., & Manik, J. R. (2023). Factors Causing Pending Claims in BPJS Participant Patients at Imelda Worker General Hospital Indonesia Medan Year 2022. Jurnal Eduhealth, 14(02), 1118–1124.
Sulaimana, A., Meliala, A., & Hendrartini, J. (2019). Pengembalian berkas klaim pasien peserta Jaminan Kesehatan Nasional (JKN) di RSUD Sultan Syarif Mohamad Alkadrie Kota Pontianak. Jurnal Manajemen Pelayanan Kesehatan, 22(1), 1–10. https://jurnal.ugm.ac.id/jmpk
Supriadi, S., & Rosania, S. (2019). Tinjauan Berkas Klaim Tertunda Pasien JKN Rumah Sakit Hermina Ciputat 2018. Jurnal Vokasi Indonesia, 7(2), 19–26. https://doi.org/10.7454/jvi.v7i2.145
Tarigan, I. N., Lestari, F. D., & Darmawan, E. S. (2022). Penundaan Pembayaran Klaim Jaminan Kesehatan Nasional Oleh Bpjs Kesehatan Di Indonesia: Sebuah Scoping Review. Jurnal Ekonomi Kesehatan Indonesia, 7(2), 108–123. https://doi.org/10.7454/eki.v7i2.6136
Triatmaja, A. B., Wijayanti, R. A., & Nuraini, N. (2022). Tinjauan Penyebab Klaim Pending Badan Penyelenggara Jaminan Sosial (Bpjs) Kesehatan Di Rsu Haji Surabaya. J-REMI : Jurnal Rekam Medik Dan Informasi Kesehatan, 3(2), 131–138. https://doi.org/10.25047/j-remi.v3i2.2252
Undang-Undang Republik Indonesia Nomor 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial.
Undang-Undang Republik Indonesia Nomor 36 Tahun 2009 tentang Kesehatan.
Widyaningrum, L., Maryati, W., & Wulandari, R. N. (2022). Identification Pending Claim of Healthcare and Social Security Agency Insurance at Nirmala Suri Hospital. Proceeding of International Conference on Science, Health, And Technology, 263–277. https://doi.org/10.47701/icohetech.v3i1.2251
Wirajaya, M. K. M., & Dewi, N. M. U. K. (2019). Analisis Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Rumah Sakit Dharma Kerti Tabanan. Jurnal Administrasi Rumah Sakit Indonesia (ARSI), 6(1), 11–20. https://doi.org/10.7454/arsi.v6i1.3553
Yastori. (2021). Cases of Dispute and Pending Claims in Hospitals in the Era of National Health Insurance. Proceeding International Conference on Medical Record, 32–38. https://doi.org/10.47387/icmr.v2i1.152
Downloads
Published
Issue
Section
License
Copyright (c) 2023 JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit)
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.