Analisis Dispute Klaim Pasien Coronavirus Disease 2019 (Covid-19) (Studi Kasus Pada Rumah Sakit X Kelas B Di Kabupaten Bantul)

BEBY ANTIKA PUTRI, Dr. drg. Julita Hendrartini, M.Kes., AAK; dr. Firdaus Hafidz, MPH., Ph.D., AAK

2022 | Tesis | MAGISTER ILMU KESEHATAN MASYARAKAT

Latar Belakang: Upaya Pemerintah dalam penanggulangan Covid-19 adalah dengan menetapkan rumah sakit rujukan Covid-19. Rumah sakit rujukan Covid-19 dapat mengajukan klaim ke Kementerian Kesehatan. Tetapi, fakta di lapangan banyak rumah sakit penanggulangan Covid-19 yang mengalami kendala pengajuan klaim Covid-19 dan banyaknya kasus dispute klaim yang menyebabkan proses pembayaran tertunda. Berkas klaim yang diajukan Rumah sakit X April sampai Juli sebanyak 138 berkas klaim dan terdapat 83 berkas dispute. Tujuan: Penelitian ini adalah menganalisis faktor yang menyebabkan dispute klaim Covid-19. Metode: Penelitian ini merupakan penelitian deskriptif dengan pendekatan kualitatif, dengan menggunakan data sekunder yang dari laporan berkas dispute klaim Covid-19 dan data primer yang dikumpulkan dari observasi dan wawancara mendalam. Hasil: Kriteria tertinggi dispute klaim di Rumahh 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. Dampak dispute klaim adalah tertundanya pembayaran jasa medis dan perawat. Kesimpulan: Kejadian dispute klaim Covid-19 disebabkan hal medis dan administrasi.

Background: The Government's effort in dealing with Covid-19 is to establish a Covid-19 referral hospital. Covid-19 referral hospitals can submit claims to the Ministry of Health. However, the facts on the ground are that many hospitals dealing with Covid-19 are experiencing difficulties in submitting Covid-19 claims and there are many cases of disputed claims that have caused the payment process to be delayed. There are 138 claim files submitted by Hospital X from April to July and there are 83 dispute files. Objective: This study is to analyze the factors that cause the Covid-19 claim dispute. Methods: This research is a descriptive study with a qualitative approach, using secondary data from the Covid-19 claim dispute file report and primary data collected from observation and in-depth interviews. Results: The highest criteria for dispute claims at Hospital X are the criteria for invalid insurance participants, incomplete claim files, comorbid diagnoses that do not match the provisions, and identity that does not match the provisions. The cause of the disputed claims of Covid-19 patients was due to inaccurate history taking, differences in perception, PCR results not attached, lack of understanding of the DPJP regarding the technical guidelines for Covid-19 claims. Obstacles in the claim submission process are regulations that have changed, application errors, completeness of medical records more than 2 x 24 hours, incomplete medical resumes, and doctors' writings that cannot be read. The impact of disputed claims is the delay in payment for medical and nursing services. Conclusion: The occurrence of the Covid-19 claim dispute was caused by medical and administrative matters.

Kata Kunci : hospital, claim dispute, cash flow, Covid-19