Evaluasi pelaksanaan verifikasi pada program jaminan kesehatan masyarakat Provinsi Daerah Istimewa Jogjakarta

RINI, Anita Afia, Prof. dr. Ali Ghufron Mukti, MSc., Ph.D

2009 | Tesis | S2 Magister Kebijakan Pembiayaan dan Manajemen Asu

Latar Belakang: Undang – Undang Dasar 1945, pasal 28 H ayat 3 menyatakan bahwa jaminan sosial adalah hak setiap warga negara. Pemerintah telah melakukan berbagai upaya untuk menjamin masyarakat miskin. Perubahan peran verifikasi dari PT Askes ke Jamkesmas. Pengajuan klaim rumah sakit mengalami penundaan. Peran verifikator belum optimal. Peneliti tertarik untuk meneliti evaluasi pelaksanaan verifikasi Jamkesmas khususnya tentang peran dan fungsi verifikator. Tujuan Penelitian: mengetahui pelaksanaan verifikasi oleh petugas verifikator program jamkesmas di Propinsi D.I.Yogyakarta. Metode Penelitian: Studi Kasus Diskriptif. Metode pengumpulan data secara kualitatif dan kuantitatif. Metode kualitatif melalui wawancara dengan tenaga verifikator. Sedangkan metode kuantitatif diperoleh dari data sekunder. Hasil Penelitian: Hasil penelitian dari evaluasi verifikasi Jamkesmas di RSUP Dr Sardjito dan RS Bethesda sudah memenuhi kriteria tepat waktu, tepat jumlah dan tepat sasaran. Administrasi klaim sudah sesuai dengan penilaian laik kepesertaan, laik medik dan laik bayar. Prosedur pelayanan dapat diakses oleh semua masyarakat miskin dengan tingkat pemanfaatan tertinggi di pelayanan rawat jalan RSUP Dr Sardjito (83%). Faktor tertinggi klaim tidak layak bayar disebabkan berkas pendukung klaim pasien (RSUP Dr Sardjito 37,5% dan RS Bethesda 24,3%) dengan jumlah selisih klaim di RSUP Dr Sardjito Rp 455.853.603 dan RS Bethesda Rp110.524.212. Kesimpulan: Verifikasi Jamkesmas sangat efektif dan efisien dilakukan karena menerapkan prinsip managed care sehingga tercipta kendali mutu dan kendali biaya. Hambatan – hambatan yang dijumpai adalah masih belum adanya sinkronisasi kebijakan yang ada di daerah terutama di tingkat kabupaten, kebijakan yang berubah - ubah, pembagian kerja dan kewenangan verifikator di setiap rumah sakit, lemahnya sistem keamanan software Jamkesmas 2008, jumlah tenaga verifikator di rumah sakit masih kurang sehingga beban kerja verifikator meningkat. Sarana yang ada di rumah sakit masih belum merata. Saran: Saran dalam pelaksanaan kedepan bagi tim pengelola pusat pembuatan petunjuk pelaksanaan harus sudah sempurna sebelum di implementasikan, pembuatan petunjuk teknis harus jelas dan software jamkesmas harus ada sistem keamanannya. Bagi rumah sakit mengefektifkan tim Jamkesmas untuk kendali biaya. Peneliti selanjutnya dapat melihat kepuasan pasien dan health provider terhadap program Jamkesmas.

Background: the law of 1945, article 28 H, subsection 3 stated that social guarantee was the right of every citizen. Government had done various efforts to guarantee poor society healthy. The change of verification roles of Askes Corporation to Jamkesmas. The submission of hospital’s claim was postponed. The roles of verificator were not optimal. Researcher was interested to do research on evaluation of verification implementation of Jamkesmas, particularly on the roles and function of verification official. Objective: to know the implementation of verification by verification official of Jamkesmas in the Province of Yogyakarta special region. Method: method which be used was case study. The methods of data collecting were qualitative and quantitative. Qualitative method was done by interview with the verification official. Meanwhile, quantitative method obtained by secondary data. Results: the results’ research of evaluation against Jamkesmas’s verification in Dr. Sarjito hospital and Bethesda hospital had occupied the criteria on the right time, sum and target. The claim administration was appropriate with the proper participant, medical and, payment. The procedure which could be accessed by all poor people with the level of highest on service take care of road in Dr. Sardjito hospital was 83 %. The highest claim factors that improper payment which caused by supporting patient bundle ( Dr. Sarjito hospital was 37, 5% and Bethesda hospital 24,3%) with the number of difference claim in Dr. Sarjito hospital was 455, 853, 603 rupiahs, and in Bethesda hospital was 110,524, 212 rupiahs. Conclusion: Jamkesmas verification was doing very effective and efficient because it applied care management, hence quality and costs was under controlled. The challenges met were there had not been synchronization of policies which exist in region, especially in regency’s area. Fickle policies, division of labor, and authority of verification official in each of hospital, weakness of security software system in 2008, a lack of verification official number in hospital still less, thus the responsibility of official verification was increased. The facilitate in hospitals was uneven. Suggestion in future implementation for organizer team center who made implementation guide should have been perfect before it was implemented, the making of technical guide have to be clear and the Jamkesmas software must be had security system.

Kata Kunci : Pedoman pelaksanaan,Klaim dan verifikasi, implementation guidance, claim and verification