FACTORS RELATED TO PENDING CLAIM IN INDONESIAN NATIONAL HEALTH INSURANCE (JKN): A SYSTEMATIC REVIEW

I Nyoman Gede Semarajana, Prastuti Soewondo

Abstract

Background: The number of Indonesian National Health Insurance (JKN) member is increasing every year. It is bringing impact to the hospital and Social Security Organizing Agency (BPJS) of health. The hospital finances will face problem if BPJS of health pending or giving a smaller number of claims paid to the hospital. The hospital will get problem with employee payroll, payment of specialist medical services, drugs availability, and maintenance of hospital facilities and medical equipment. This study aims to analyze factors related to pending BPJS claim in Indonesian National Health Insurance. Methods: This study was a systematic review used PRISMA (Preferred Reporting Items for Systematic Reviews & Meta-Analyses) guidelines. Data obtained from journal database of Google Scholar that published between 2014-2019. The relevant studies must include factors related to pending claim in JKN.

Results: The search found out 217 studies, of which 84 studies used English and Indonesia language and only 5 studies that eligible for this study. The 5 studies showed factors related to pending claim in JKN were human resources, administration, regulation, facilities, external and evaluation factors. Human resources factor more likely appeared as cause for pending BPJS claim.

Conclusion: Factors related to pending claim in JKN were human resources, administration, regulation, facilities, external and evaluation factors. Human resources was the factor that most influenced for pending BPJS claim. The hospital must create strategies to overcome the factors that cause pending claim. The government should create a policy that can help BPJS of health overcome the deficit and protect the patients from facing decrease in the quality of hospital services.

Full Text:

PDF

References

Presiden Republik Indonesia. Undang - undang RI No. 40 Tahun 2004 tentang Sistem Jaminan Sosial Nasional (Law of the Republic of Indonesia No. 40 of 2004 concerning the National Social Security System). 2004;1–16. Available from: http://www.komnasham.go.id/sites/default/files/dokumen/UU NO 39 TAHUN 1999 HAM_0.pdf

Thabrany H. Jaminan Kesehatan Nasional. Edisi Kedua. (National Health Insurance, 2nd Edition). Jakarta: PT RajaGrafindo Persada; 2016.

Presiden Republik Indonesia. Undang - undang RI No. 24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial (Republic of Indonesia Law No. 24 of 2011 concerning the Social Security Organizing Agency). 2011;

Agustina R, Dartanto T, Sitompul R, Susiloretni KA, Suparmi, Achadi EL, et al. Universal Health Coverage in Indonesia: Concept, Progress, and Challenges. Lancet. 2018;393(10166):1–28.

Tandon, Ajay; Pambudi, Eko Setyo; Harimurti, Pandu; Masaki, Emiko; Subandoro, Ali Winoto; Yasmin Chrysanti, Puti; Rajan, Vikram Sundara; Dorkin, Darren W.; Chandra, Amit; Boudreaux, Chantelle; Pei Lyn, Melissa Chew; Suharno N. Indonesia Health System Assessment: Spend More, Right, and Better [Internet]. Washington, D.C: World Bank Group; 2016. Available from: http://documents.worldbank.org/curated/en/453091479269158106/Indonesia-Health-financing-system-assessment-spend-more- right-and-better

BPJS Kesehatan. Peserta dan Provider JKN [Internet]. Vol. 996. 2019. Available from: https://faskes.bpjskesehatan.go.id/aplicares/#/app/peta

Republik Indonesia. Peta Jalan Menuju Jaminan Kesehatan Nasional 2012 - 2019 (Roadmap to National Health Insurance 2012 - 2019). Jakarta: Dewan Jaminan Sosial Nasional; 2012.

Kementerian Sekretariat Negara RI Sekretariat Wakil Presiden. JKN: Perjalanan Menuju Jaminan Kesehatan Nasional (Journey to National Health Insurance) [Internet]. Jakarta Pusat: Tim Nasional Percepatan Penanggulangan Kemiskinan; 2015. Available from: http://www.tnp2k.go.id/images/uploads/downloads/Final_JKN_Perjalanan Menuju Jaminan Kesehatan Nasional - Copy.pdf

Citra Y, Thabrani H. Delayed Claim Payment And The Threat To Hospital Cash Under The National Health Insurance Scheme In Indonesia. roceedings of International Conference on Applied Science and Health. 2018;(3):122–8.

Presiden Republik Indonesia. Peraturan Presiden RI No. 82 Tahun 2018 tentang Jaminan Kesehatan (Regulation of The President of Republic of Indonesia No. 82 of 2018 concerning Health Insurance). 2018.

Kemenkes RI. Permenkes RI No 76 Tahun 2016 Tentang Pedoman Indonesia Case Base Group (INA-CBG) (Regulation of the Minister of Health Republic of Indonesia No. 76 of 2016 concerning Guidelines for Indonesian Case Base Groups (INACBGs) in Implementing National Health Insurance). 2016;1–257.

WHO Regional Office for South-East Asia. The Republic of Indonesia Health System Review [Internet]. Vol. 7, World Health Organization. 2017. Available from: http://apps.who.int/iris/bitstream/10665/254716/1/9789290225164-eng.pdf

Valentina, Halawa MNS. Analisis Penyebab Unclaimed Berkas BPJS Pasien Rawat Inap Di Rumah Sakit Umum Imelda Pekerja Indonesia (RSU IPI) Medan (Analysis of Causes of Unclaimed Inpatient BPJS File in Indonesian Workers Imelda Hospital (IPI Hospital) Medan). Ilmu Perekam Dan Informasi Kesehatan Imelda. 2018;3(2):480–5.

Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, et al. Preferred Reporting Items for Systematic Reviews and Meta- Analyses: The PRISMA Statement. PLoS Med. 2009;6(7):1–6.

Nurdiah RS, Iman AT. Analisis Penyebab Unclaimed Berkas BPJS Rawat Inap Di RSUD Dr. Soekardjo Tasikmalaya (Analysis of Causes of Unclaimed Inpatient BPJS File in Dr. Soekardjo Tasikmalaya Hospital). Jurnal Manajemen Informasi Kesehatan Indonesia. 2016;4(2):23–8.

Artanto AE. Faktor - Faktor Penyebab Klaim Tertunda BPJS Kesehatan RSUD Dr. Kanujoso Djatiwibowo Periode Januari - Maret 2016 (Factors Causes of Claim Delayed Health BPJS Dr. Kanujoso Djatiwibowo Period January - March 2016). Jurnal Administrasi Rumah Sakit. 2016;4:38–50.

Irmawati, Kristijono A, Susanto E, Belia Y. Cause Of Fair Reverse Claims Of Social Security Institution (BPJS) Patients Representative Required From Terms Of Claims In RSUD R.A Kartini Jepara. Jurnal Rekam Medis dan Informasi Kesehatan. 2018;1(1):45–51.

Sakyi EK, Atinga RA, Adzei FA. Managerial Problems of Hospitals Under Ghana’s National Health Insurance Scheme. Clinical Governance An International Journal. 2012;17(3):178–90.

Atinga RA, Mensah SA, Asenso-Boadi F, Adjei FXA. Migrating from User Fees to Social Health Insurance: Exploring The Prospects and Challenges for Hospital Management. BMC Health Services Research. 2012;12(1):1–10.

Noviatri LW, Sugeng S. Analisis Faktor Penyebab Keterlambatan Penyerahan Klaim BPJS di RS Panti Nugroho (Analysis of the Causes of Delays in Submitting BPJS Claims at Panti Nugroho Hospital). Jurnal Kesehatan Vokasional. 2016;1(1):22–6.

Refbacks

  • There are currently no refbacks.