Evaluation of claim submission and returning for BPJS inpatient services: a case study of hospital X in 2017

Latar belakang: Keterlambatan dan ketidaklengkapan pengajuan klaim menyebabkan keterlambatan pembayaran klaim yang akan berdampak pada arus kas rumah sakit (RS). Artikel ini bertujuan untuk menilai pengajuan dan pengembalian klaim pada pelayanan rawat inap pasien BPJS. Metode: Penelitian potong lintang dengan desain studi kasus. Sumber data menggunakan data pengajuan dan pengembalian klaim rawat inap pasien BPJS periode Januari-Juni 2017. Data dianalisis secara deskriptif. Hasil: Frekuensi pengajuan klaim rawat inap terbanyak 17 kali dan terendah 13 kali dalam sebulan, yang berarti RS mengajukan klaim ke BPJS hampir setiap 2-3 hari sekali.Dari 11,945 berkas klaim, sebanyak 3,013 (25,2%) berkas klaim dikembalikan ke RS oleh BPJS. Nilai klaim yang diajukan untuk 11,945 berkas adalah Rp. 146,967,494,700, sedangkan nilai klaim dari berkas yang dikembalikan sebesar Rp. 45,150,888,100-. Alasan berkas dikembaliakn antara lain masalah administrasi, ketidaklengkapan resume medis, pemeriksaan penunjang, konfirmasi koding, tidak layak, pinjam status, dan TXT yang tidak terbaca. Penyebab paling banyak berkas dikembalikan adalah konfirmasi koding (42,4%) dan ketidaklengkapan resume medis (30,3%). Kesimpulan: Tampaknya RS tidak pernah mengalami keterlambatan dalam pengajuan klaim, namun berkas klaim yang dikembalikan BPJS masih banyak, yang utamanya disebabkan oleh permasalahan koding dan ketidaklengkapan resume medis.  Kata kunci: Penilaian, klaim, pengajuan, pengembalian.   Abstract   Background: Incomplete and late claim submission may result in the delay of claim payment. The impact of late payment will certainly disrupt the cash flow of the hospital. This study aims to evaluate the claim submission and returning for BPJS inpatient services. Methods: This was cross sectional study with a case study design approach. The source of data used was submission and returned claim data from hospital financing department during the period of January to June 2017. The data were analyzed descriptively. Results: The highest frequency for inpatients claim submission was 17 times and the lowest was 13 times. The hospital submit the claim file almost every 2-3 days. Of the 11.945 inpatient claims, as many as 3.013 claim files were returned by BPJS. The total claim amounts of 11,945 files was Rp. 146.967.494.700,- and, the total amount of returned claim was Rp. 45.150.888.100,-. The reasons of claim returned including administrative completeness, incomplete summary discharge , confirmation of coding, inappropriate files, unreadable TXT in BPJS application and supporting examination. The most common causes of claim files returned was confirmation of coding (42.4%) and incompleteness of discharge summary (30.3%). Conclusion: The hospital was never late in submitting claim documents but the claim returned by BPJS were still high. The most common causes of claim returned to the hospital was coding confirmation and incompleteness of discharge summary. Keywords: Evaluation, claim, submission, returning