Gambaran Faktor Penyebab Klaim Pending Rawat Inap Pasien Jaminan Kesehatan Nasional (JKN) di RSUD Kota Malang
DOI:
https://doi.org/10.36086/jpp.v20i2.3141Keywords:
Klaim Pending, Rumah Sakit, JKNAbstract
Latar Belakang: Pemerintah bertanggung jawab dalam penyelenggaraan layanan kesehatan bermutu melalui rumah sakit, termasuk dalam pelaksanaan program JKN yang mencakup layanan promotif, preventif, kuratif, dan rehabilitatif. Rumah sakit mengajukan klaim ke BPJS Kesehatan melalui sistem INA-CBGs yang memverifikasi klaim berdasarkan prosedur medis, kode, dan administrasi; namun jika terjadi klaim pending yang membutuhkan verifikasi tambahan, hal ini dapat mengganggu arus kas rumah sakit sehingga penting untuk mengidentifikasi penyebabnya agar efisiensi sistem klaim dapat ditingkatkan. Tujuan Penelitian : Mengetahui faktor-faktor penyebab klaim pending rawat inap pasien JKN di RSUD Kanjuruhan Malang.
Metode: Jenis penelitian menggunakan metode deskriptif kuantitatif dan lokasi penelitian terletak di RSUD Kanjuruhan Malang. Populasi yang digunakan yaitu berkas klaim pending rawat inap periode Januari – Juli 2024 sebanyak 913 berkas sedangkan sampel penelitian diambil dengan simple random sampling sebanyak 278 berkas. Variabel penelitian yaitu faktor penyebab klaim pending berdasarkan aspek administrasi, koding, dan medis serta instrumen penelitian menggunakan lembar checklist.
Hasil: Penyebab klaim pending rawat inap dari aspek administrasi sebesar 29 berkas (10%), aspek koding sebesar 91 berkas (33%), dan aspek medis sebesar 158 (57%). Penyebab klaim pending pada aspek administrasi disebabkan oleh Potensi readmisi, Hak kelas rawat tidak sesuai, Berkas klaim belum terlampir, Tidak melampirkan laporan operasi dan hasil pemeriksaan penunjang, GL JR tidak dijamin, Ketidaklengkapan pengisian tanggal masuk dan keluar rumah sakit, dan Potensi rujukan self referral. Penyebab klaim pending pada aspek koding disebabkan oleh Kode tidak sesuai dengan kaidah pengkodean klinis dan BA Kesepakatan, Ketidaktepatan pemberian kode ganda, Ketidaktepatan penulisan kode diagnosis dan tindakan, dan Ketidaktepatan penegakan diagnosa utama dan diagnosa sekunder. Penyebab klaim pending pada aspek medis disebabkan oleh Kurangnya penjelasan penunjang penguat dan tata laksana pada diagnosa, Ketidaksesuaian diagnosa dengan kriteria gejala klinis berdasarkan PNPK, Kurangnya informasi hasil baca penunjang, Kurangnya informasi indikasi rawat inap, Kurangnya informasi terkait kejadian baru atau sequele, dan Kurangnya eviden terapi.
Kesimpulan: Faktor dominan dari penyebab klaim pending adalah pada aspek medis, saran untuk rumah sakit yaitu memastikan kelengkapan dokumen, keakuratan kode diagnosis dan prosedur, serta penanganan medis sebelum mengajukan klaim ke BPJS Kesehatan.
Kata kunci : Klaim Pending, Rumah Sakit, JKN.
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