TINJAUAN PENYEBAB KLAIM PENDING BADAN PENYELENGGARA JAMINAN SOSIAL (BPJS) KESEHATAN DI RSU HAJI SURABAYA

Badan Pelaksana Jaminan Sosial (BPJS) Kesehehatan provide health services to the public by using a prospective payment system. Surabaya Hajj General Hospital is one of the type B educational hospitals that has been collaborating with the BPJS since 2014. Based on primary data at Surabaya Haji Hospital it was found that the claim file had pending claims. This is due to incomplete claim file, inaccurate diagnostic code due to differences in perception between the coders and verifiers. This study aims to analyze the pending claims factor of the Health Social Security Administration Agency (BPJS) at Haji Hospital Surabaya. Problem identification uses 5M management elements (man, material, methods, machine, money). This type of research is descriptive qualitative, narrating the results of the study. In the man element that causes the pending claim is the officer still feels difficulty in reading the diagnoses and actions of patients due to the writing of doctors who are difficult to read, and incorrect diagnosis codes and actions due to differences in perception between the coder and verifier of the BPJS. The material element that causes the pending claim is the incomplete claim file, such as the results of patient support examinations. In the Method element that causes pending claims, there is no SOP governing the filling of a specific diagnosis file claim. On the machine element that causes pending claims is the computer used in the claim submission process often experiences long loading times and often experiences network disruptions. In the element of money in this study does not cause pending claims, because casemix officers can not know the amount of loss caused by pending claims.Abstrak Badan Pelaksana Jaminan Sosial Kesehatan (BPJS) memberikan pelayanan kesehatan kepada masyarakat dengan menggunakan sistem pembayaran secara prospektif. Rumah Sakit Umum Haji Surabaya merupakan salah satu rumah sakit tipe B pendidikan yang bekerja sama dengan pihak BPJS sejak tahun 2014. Berdasarkan data primer di RSU Haji Surabaya ditemukan permasalahan bahwa berkas klaim mengalami pending klaim. Hal ini dikarenakan tidak lengkapnya berkas klaim, ketidaktepatan kode diagnosa karena adanya perbedaan persepsi antara koder dengan verifikator. Penelitian ini bertujuan untuk menganalisis faktor klaim pending Badan Penyelenggaraan Jaminan Sosial Kesehatan (BPJS) di RSU Haji Surabaya. Identifikasi permasalahan menggunakan unsur manajemen 5M (man, material, methods, machine, money). Jenis penelitian ini adalah kualitatif deskriptif yaitu menarasikan hasil penelitian. Pada unsur man yang menjadi penyebab klaim pending adalah petugas masih merasa kesulitan dalam membaca diagnosa dan tindakan pasien dikarenakan penulisan dokter yang sulit terbaca, dan tidak tepatnya kode diagnosa dan tindakan yang dikarenakan adanya perbedaan persepsi antara koder dan verifikator BPJS. Pada unsur material yang menjadi penyebab klaim pending yaitu tidak lengkapnya berkas klaim seperti hasil pemeriksaan penunjang pasien. Pada unsur Method yang menyebabkan klaim pending adalah tidak terdapat SOP yang mengatur tentang pengisisan diagnosis khusus berkas klaim. Pada unsur machine yang menyebabkan klaim pending adalah komputer yang digunakan dalam proses pengajuan klaim sering mengalami loading lama dan sering mengalami gangguan jaringan. Pada unsur money dalam penelitian ini tidak menyebabkan klaim pending, karena petugas casemix tidak dapat mengetahui jumlah kerugian yang diakibatkan oleh klaim pending. Kata Kunci: faktor klaim pending, man, material, methods, machine, moneyAbstractBadan Pelaksana Jaminan Sosial (BPJS) Kesehehatan provide health services to the public by using a prospective payment system. Surabaya Hajj General Hospital is one of the type B educational hospitals that has been collaborating with the BPJS since 2014. Based on primary data at Surabaya Haji Hospital it was found that the claim file had pending claims. This is due to incomplete claim file, inaccurate diagnostic code due to differences in perception between the coders and verifiers. This study aims to analyze the pending claims factor of the Health Social Security Administration Agency (BPJS) at Haji Hospital Surabaya. Problem identification uses 5M management elements (man, material, methods, machine, money). This type of research is descriptive qualitative, narrating the results of the study. In the man element that causes the pending claim is the officer still feels difficulty in reading the diagnoses and actions of patients due to the writing of doctors who are difficult to read, and incorrect diagnosis codes and actions due to differences in perception between the coder and verifier of the BPJS. The material element that causes the pending claim is the incomplete claim file, such as the results of patient support examinations. In the Method element that causes pending claims, there is no SOP governing the filling of a specific diagnosis file claim. On the machine element that causes pending claims is the computer used in the claim submission process often experiences long loading times and often experiences network disruptions. In the element of money in this study does not cause pending claims, because casemix officers can not know the amount of loss caused by pending claims. Keywords: pending claim factor, man, material, methods, machine, mone