DISPUTE ANALYSIS OF CLAIMS FOR PATIENTS WITH COVID-19: A CASE STUDY AT HOSPITAL X CLASS B IN BANTUL REGENCY

Authors

Beby Antika Putri, Faculty of Medicine, Public Health and Nursing, Gajah Mada University, Daerah Istimewa Yogyakarta, IndonesiaFollow
Firdaus Hafidz, Faculty of Medicine Public Health and Nursing Universitas Gadjah Mada Yogyakarta, IndonesiaFollow
Yulita Hendrartini, Faculty of Medicine, Public Health and Nursing, Gajah Mada University, Daerah Istimewa Yogyakarta, IndonesiaFollow

Abstract

The Indonesian Government established referral hospitals for COVID-19 as an effort in combating the pandemic. Referral hospitals for COVID-19 submit their services’ claims to the Ministry of Health. Hospital X in Bantul experienced challenges in submitting COVID-19 claims and underwent claim disputes which caused delays in payment process. This research aimed to explore the factors that led to the disputes over the COVID-19 claims. This descriptive research was conducted with a qualitative approach, using in-depth interviews and observations. The additional descriptive analysis used secondary data COVID-19 claim dispute file reports from 2020. The results showed that the highest criteria of disputed claims at Hospital X were the criteria for non- compliant guaranteed participants, incomplete claim files, non-compliant comorbid diagnoses, and identities that did not comply with the provisions. The causes of the disputes over claims for patients with COVID-19 included inaccurate history taking, differences in regulation perceptions between the provider and payer, PCR results were not provided, and doctors had a lack of understanding regarding the technical guidelines for COVID-19 claims. In addition, there were technical problems faced by the hospital during the process of submitting claims, including regulations were changed frequently, errors in applications, incomplete medical resumes, and unreadable doctors’ writings. Disputed claims did not affect the hospital cash flow, yet delayed the payment process to health workers, which might harm the quality of services.

Bahasa Abstract

Upaya Pemerintah Indonesia dalam penanggulangan COVID-19 adalah dengan menetapkan rumah sakit rujukan pandemic ini. Rumah sakit rujukan COVID-19 dapat mengajukan klaim ke Kementerian Kesehatan. Rumah Sakit X di Bantul dalam mengajukan klaim COVID-19 mengalami kendala dan adanya kasus dispute klaim yang menyebabkan proses pembayaran klaim tertunda. Penelitian ini bertujuan untuk menganalisis faktor-faktor yang menyebabkan dispute klaim COVID-19. Jenis penelitian ini merupakan penelitian deskriptif dengan pendekatan kualitatif, dengan wawancara mendalam dan observasi, ditambah analisis deskriptif menggunakan data sekunder yaitu laporan berkas dispute klaim COVID-19 tahun 2020. Hasil penelitian menunjukkan bahwa kriteria tertinggi dispute klaim di Rumah Sakit X adalah kriteria peserta jaminan tidak sesuai, berkas klaim tidak lengkap, diagnosa komorbid tidak sesuai ketentuan, dan identitas tidak sesuai ketentuan. Penyebab dispute klaim pasien COVID-19 disebabkan karena ketidaktepatan anamnesis, perbedaan persepsi, hasil PCR tidak terlampir, kurangnya pemahaman DPJP mengenai juknis klaim COVID-19. Kendala dalam proses pengajuan klaim adalah regulasi yang mengalami perubahan, aplikasi eror, kelengkapan rekam medis lebih dari 2 x 24 jam, ketidaklengkapan resume medis, dan tulisan dokter yang tidak dapat dibaca. Dispute klaim tidak berdampak pada permasalahan cash flow rumah sakit, tapi menunda pembayaran jasa medis dan perawat, dan dapat menurunkan kualitas layanan.

Recommended Citation

Putri, Beby Antika; Hafidz, Firdaus; and Hendrartini, Yulita (2023) "DISPUTE ANALYSIS OF CLAIMS FOR PATIENTS WITH COVID-19: A CASE STUDY AT HOSPITAL X CLASS B IN BANTUL REGENCY," Journal of Indonesian Health Policy and Administration: Vol. 8: No. 1, Article 2.
DOI: 10.7454/ihpa.v8i1.6271
Available at: https://scholarhub.ui.ac.id/ihpa/vol8/iss1/2