Tinjauan Penyebab Pengembalian Berkas Klaim Kasus Gawat Darurat

Agiwahyuanto, Faik; Anjani, Sylvia; Juwita, Arinda

doi:10.33560/jmiki.v9i2.318

Cited by 3 publications

(2 citation statements)

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“…In a similar study, there were file returns because several files were submitted for emergency claims considered non-emergency by the Social Health Insurance Administration Body verifier. After all, they did not meet the criteria for emergency conditions, according to the Social Health Insurance Administration Body (Agiwahyuanto et al, 2021).…”

Section: Incompleteness Of Claims Administrationmentioning

confidence: 99%

Factors Causing Pending Claims at Nyi Ageng Serang Regional General Hospital

Utami,

Budi,

Septiawan

2023

JMMR

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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.

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Section: Incompleteness Of Claims Administrationmentioning

confidence: 99%

Factors Causing Pending Claims at Nyi Ageng Serang Regional General Hospital

Utami,

Budi,

Septiawan

2023

JMMR

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“…Didukung oleh penelitian yang dilakukan oleh penelitian yang dilakukan oleh Faik Agiwahyuanto, Sylvia Anjani dan Arinda Juwita terkait penyebab pengembalian berkas klaim kasus gawat darurat dimana didapatkan bahwa resume medis pasien gawat darurat yang dimana sebagai salah satu syarat untuk pengajuan klaim BPJS kesehatan harus berisikan ringkasan pulang yang mengenai identitas pasien, alasan dirawat, riwayat penyakit, pemeriksaan fisik, pemeriksaan penunjang, tindakan, terapi yang diberikan dan obat yang dibawa pulang, keadaan pulang pasien, waktu kontrol, edukasi pasien, dan authentifikasi (Agiwahyuanto, Anjani, & Juwita, 2021).…”

Section: Persentase Pengembalian Klaim Bpjs Pasien Rawat Inap DI Rskd...unclassified

Tinjauan Faktor Penyebab Pengembalian Klaim BPJS Pasien Rawat Inap di RSKD Duren Sawit Jakarta Timur Tahun 2021

Sander,

Indawati,

Widjaja

et al. 2022

Sehat Rakyat: Jurnal Kesehatan Masyarakat

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BPJS claim returns have 2 types of returns, the first is a purification failure or a return that occurs due to incompatibility and incompleteness of patient administration, such as patient eligibility letter number (SEP), class of care, and way of returning the patient. The second is pending, this return occurs due to discrepancies and incomplete diagnoses, diagnosis codes and service files received by inpatient BPJS patients submitted to BPJS. Therefore, officers must have thoroughness and understanding when carrying out their duties. This study was conducted to determine the factors causing the return of BPJS claims for inpatients at the Duren Sawit Hospital, East Jakarta in 2021 using a descriptive quantitative approach, by providing an overview and results regarding the factors causing the return of BPJS claims for inpatients. The results of the study used 227 samples of claim files that were returned by the BPJS verifier and obtained 2 (two) types of claim returns. 54 (23.8%) failed to be purified and 173 (76.2%) pending claim files. The most reason for returning claims is that the diagnosis is not supported by treatment and supporting results. There are 2 factors hindering the identification of 5M. Man factor: human error, competence of officers, and the absence of a casemix team. Material: inaccuracy of diagnosis in electronic medical resume so that there is inaccuracy when coding patient diagnosis. There are no barriers to the Money, Method, Machine factors. To get maximum results when submitting BPJS claims for inpatients, hospitals should pay attention to the competence of officers and socialize policies that are in accordance with the system run by the hospital.

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Decoding Health Care Complexity with Investigating Pending Claims in Indonesia

Sari,

Cholifah

2024

jims

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This study investigates the factors contributing to pending claims at Muhammadiyah Lamongan Hospital, focusing on work ability, performance, and work motivation among casemix officers. Conducted from May to July 2023, the research utilizes a descriptive quantitative approach with a sample of 342 pending hospitalization claim files. Findings reveal that code discrepancies, incomplete membership administration, and service discrepancies are the main causes of pending claims. Results show significant relationships between motivation and performance, ability and motivation, and performance and work ability of casemix officers, influencing pending claims occurrence. Lack of training and mismatches between job requirements and qualifications also contribute. The study underscores the importance of monitoring and evaluation, standard operating procedures (SOPs), and continuous training for casemix officers to mitigate pending claims, thereby enhancing the efficiency of health care services. Hightligh: 1. Main Causes: Code discrepancies, incomplete administration, and service discrepancies.2. Key Relationships: Motivation, performance, ability affect pending claims occurrence.3. Implications: Monitoring, standard procedures, and training improve health care efficiency. Keywords: pending claims, casemix officers, Muhammadiyah Lamongan Hospital, health care management, quantitative research

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Tinjauan Penyebab Pengembalian Berkas Klaim Kasus Gawat Darurat

Cited by 3 publications

References 0 publications

Factors Causing Pending Claims at Nyi Ageng Serang Regional General Hospital

Factors Causing Pending Claims at Nyi Ageng Serang Regional General Hospital

Tinjauan Faktor Penyebab Pengembalian Klaim BPJS Pasien Rawat Inap di RSKD Duren Sawit Jakarta Timur Tahun 2021

Decoding Health Care Complexity with Investigating Pending Claims in Indonesia

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