ANALYSIS OF PENDING CLAIMS DUE TO INCOMPATIBILITY OF DIAGNOSTIC AND ACTION CODES IN INPATIENTS IN HOSPITALS

Authors

  • Puguh Ika Listyorini Duta Bangsa University
  • Nadia Arifah Ramadhan Universitas Duta Bangsa Surakarta

DOI:

https://doi.org/10.47701/icohetech.v3i1.2257

Keywords:

National Health Insurance, pending claims, coding discrepancies

Abstract

This research was conducted at UNS Sukoharjo Hospital. Based on the preliminary study, it was found that 19.5% of the claims filed were pending in inpatient claims and 31% were due to coding cases. This study was conducted to determine pending claims due to coding discrepancies in hospitalized National Health Insurance patients.

This is a case study research type with a qualitative research design. Data were taken by observation and interviews with the head of the medical record installation room, coding officer, head of the guarantee installation room, and the verifier of the Health Insurance Administration. The data collected, presented descriptively, and analyzed using content analysis techniques.

The results showed that the coding of claim files had been carried out according to hospital standards. Submission of the claim file is carried out after verification by the internal verifier. The pending claim occurs due to a mismatch in coding caused by the need for a join code, an error in determining the main diagnosis, the need for confirmation of the action code, and the need for confirmation of supporting reports. Other influencing factors are support from colleagues, technology support, limited knowledge, and lack of staff training, as well as system changes and problematic servers both from hospitals and from Health Insurance Providers.

The conclusion is that there are still pending claims caused by coding cases, so it is better for officers to take coding training and perform server maintenance.

References

Bowman, E, & Abdelhak, Mervat. 2001. Coding, classification, and reimbursement systems. Health information: management of a strategic resource. 2nd edition. Philadelphia: WB Saunders Company, 229-258.

Bungin, Burhan. 2007. Book of Sociology of Communication Theory & Practice. Bandung: Symbiosis Rekatama Media

Indonesian government. 2004. Law of the Republic of Indonesia Number 40 concerning the National Social Security System. Jakarta: Ministry of Health.

Indonesian government. 2011. Law of the Republic of Indonesia Number 24 concerning the establishment of the Social Security Administering Body. Jakarta: Ministry of Health.

Ministry of Health . 2014. Regulation of the Minister of Health No. 27 of 2014 concerning Technical Guidelines for the INA-CBGs System. Jakarta: Indonesian Ministry of Health.

Naga, S. Sholeh. (2012). Complete Guide to Science. Jogjakarta.: Diva Press

O'Malley, Kimberly J., Cook., Karon F., Price, Matt D., Wildes, Kimberly Raiford, Hurdle, John F., & Ashton, Carol M. 2005. Measuring Diagnostics: ICD Code Accuracy. Health Services Research, 40(5p2), 1620-1639. doi: 10.11111/j.1475-6773.

Saryono and Anggraeni, Dwi Mekar, 2013. Qualitative research methodology in the health sector. Yogyakarta: Nuha Medika.

Sari, Islami Novita. 2020. “Literature Review: The Accuracy of Giving Main Diagnostic Codes to Inpatients on Approval of Claims in Hospitals”. Thesis. Makassar : Stikes Panakkukang.

Social Security Administrator. 2014. Handbook of National Health Insurance Socialization in the National Social Security System. Jakarta: Directorate of Services 2014

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Published

2022-09-17