Factors Causing Delayed Claims At The Hospital In Collaboration With Health Social Security Agency Branch Office Of Tasikmalaya

Abstract

The Government's efforts to reduce the cost of health services and improve the health of the Indonesian people have been carried out by the National Health Insurance Program by the Health Social Security Agency (BPJS), Health Social Security Agency is the Health Social Security Administering Body which is a legal entity formed to administer the health insurance program. social services that work closely with health facilities to help Indonesian people to obtain basic health services. The hospital is an advanced level health facility that serves National Health Insurance participants on condition that they have collaborated with Health Social Security Agency to be able to organize the National Health Insurance program. Based on previous studies, there are still pending claims in various hospitals throughout Indonesia, thus disrupting hospital cashflow. Research Objectives: To find out the factors causing pending claims for BPJS health in hospitals in collaboration with Health Social Security Agency (BPJS) branch office of Tasikmalaya. Research Methods: The type of research used is descriptive with a qualitative approach Research Results: from the results of the study it is known that the contributing factors include billing and payment of chronic drug claims, claims that are not in accordance with the provisions of the treatment episode, billing claims with diagnostic codes and procedures that not in accordance with the 2010 ICD-10 and ICD-9 CM coding rules, other coding rules and guidelines for the management of claims problem solutions, traffic accident claims that are not in accordance with the provisions and are billed in a fragmented manner. Conclusion: Currently, in general, BPJS claims at advanced health facilities in collaboration with Health Social Security Agency (BPJS) branch office of Tasikmalaya are going well, there are still several causes of pending claims that can be improved, suggestions need to be done. Analysis of the level of knowledge of HR in the Hospital Casemix section, there is a need for an application to assist in the settlement of claims in terms of warnings or blocking of regulatory rules as well as evaluating the utilization review of each hospital on the services provided.

Keywords: Health insurance administration body, Pending, Claim