KLAIM TIDAK LAYAK BAYAR PESERTA JAMINAN KESEHATAN NASIONAL DI LAYANAN RAWAT JALAN RUMAH SAKIT JIWA PROF. DR. SOEROJO, MAGELANG

THE UNFEASIBLE PAYMENT CLAIM FACTORS OF NATIONAL HEALTH INSURANCE PARTICIPANTS IN PROF. DR. SOEROJO MAGELANG MENTAL HEALTH HOSPITAL'S OUT-PATIENT SERVICE

Abstract

Background: The hospital payment mechanism in National

Health Insurance era used INA-CBG's package tarif. The

service payment which had given by hospital was paid by

Indonesian National Health Insurance Agency with claiming

mechanism. There were several factors and causes that

affected unfeasible payment claim which could harm the

hospital.

Objective: Identify the factors that caused the unfeasible

payment claim, identify the cause of the unfeasible payment

claim, describe the attitude of doctors, the attitude of the leader

ship of the hospital, the attitude of the administration RSJS,

attitude BPJS Health Magelang and describe RSJS leadership

communication to the cause of the unfeasible payment claim in

the outpatient service RSJS.

Method: This research was an exploratory case study research

with single holistic case study design. Analysis unit in this

research was outpatient services in Prof. dr. Soerojo Magelang

Mental Health Hospital. Research informants were specialized

doctor and general practitioner RSJS, Prof. dr. Soerojo

Magelang Mental Health Hospital's leaders, Prof. dr. Soerojo

Magelang Mental Health Hospital's administrators, and

Indonesian National Health Insurance Agency branch in

Magelang City. The informant selection used purposive

sampling. Data collection used in-depth interview and

document observation. Result: The cause of unfeasible

payment claim consisted of medical services cause and

administrative cause. The cause of medical services most that

one episode of outpatient, one episode of inpatient and

diagnosis is not emergency. The data difffference between BPJS

Kesehatan and medical record, non-emergency diagnosis that

considered as emergency diagnosis, one episode of

outpatient/inpatient considered as two episodes of

outpatient/inpatient. The communication RSJS leaders about

unfeasible payment claim is not optimal, the attitude doctor's

with less information, the rules have not been clearly linked

specifificity RSJS in healthcare delivery, indifffference claim

services were they have rendered to the participant JKN,

understanding verififier BPJS about medically less in determining

the unfeasible payment claim into inconsistencies, too tight in

the verifification process and the workload verififier BPJS in RSJS

large enough can increase in unfeasible payment claim .The

attitude of the leadership of RSJS own conduct follow-up but

followup information was not communicated to the doctor RSJS,

the attitude of the administration RSJS who respond positively

to minimize the unfeasible payment claim.

Conclusion: The leaders' communication, doctor's attitude,

Indonesian National Health Insurance Agency's attitude and the

unpresented operational standard, and procedure in

determining steps of unfeasible payment claim were factors that

could enhance the incidence of unfeasible payment claim.