scholarly journals Physicians’ Behavior in Referring National Health Insurance Patients to Hospital

2022 ◽  
Vol 6 (2) ◽  
Author(s):  
Natalia Natalia ◽  
Haerawati Idris
Keyword(s):  
Public Health ◽  
Health Insurance ◽  
National Health Insurance ◽  
National Health ◽  
Qualitative Method ◽  
Severe Disease ◽  
Health Centers ◽  
Referral System ◽  
Primary Health ◽  
Icd 10

Physicians’ decision to refer patients in primary health care is vital in supporting the referral system. The increase of referral cases impacted the claims cost and hospital workload. This study aimed to analyze the physicians’ behavior in referring National Health Insurance (NHI) patients to hospitals. This study employed a qualitative method; 18 informants were selected using purposive sampling and analyzed using content analysis. The data were validated by triangulating method, source, and data. Physicians referred patients when the cases could not be handled; there were indications of severe disease and required further examination. The obstacles in the referral system were pressure from NHI patients that wanted to be referred and diagnosed differently from ICD 10. In referring NHI patients, physicians had followed referral procedures and criteria. High referrals were caused by patients being forced to be referred, coming with complaints of severe disease, having examined in a hospital, and some cases should not be referred to but still referred by entering a similar diagnosis into the ICD 10. It is expected that public health centers will educate NHI patients related to tiered referral procedures in health services.

Effectivity of National Health Insurance on Maternal Health in Developing Countries: A Systematic Review

2020 ◽  
Author(s):  
Eva Nur Octavia ◽  
◽  
Pandu Riono ◽  
Keyword(s):  
Public Health ◽  
Systematic Review ◽  
Developing Countries ◽  
Health Insurance ◽  
Maternal Health ◽  
National Health Insurance ◽  
National Health ◽  
Population Studies

Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Indonesia

Cases of Dispute and Pending Claims in Hospitals in the Era of National Health Insurance

2022 ◽  
Vol 2 (1) ◽  
pp. 32-38
Author(s):  
Mrs. Yastori
Keyword(s):  
Health Insurance ◽  
Health Services ◽  
National Health Insurance ◽  
National Health ◽  
National Health Insurance System ◽  
Quality Health ◽  
Icd 10 ◽  
Data Collection Technique ◽  
Observation Method

Background: Indonesia began to implement a National Health Insurance System based on the National Social Security System in 2014 with the support of government regulations which states that Indonesia requires every citizen to have access to comprehensive and quality health services so that can continue their life through the National Health Insurance. Pending and dispute claims are problems that often occur in the era of national health insurance that can affect hospital budget allocation and planning policies, increasing the high cost burden for hospitals which will affect the quality of health services provided. The purpose of this study was to determine pending cases and dispute claims in hospitals in the Era of National Health Insurance.Methods: The study used a descriptive method with a qualitative approach. The data collection technique used is the observation method, namely directly to the e-claim file at several hospitals. 15 e-claim files taken in total from April – July 2021.Results: Obtained 13 cases of pending claims and 2 cases of dispute claims. Cases pending claims are caused by not complying with the code with evidence or resources, not in accordance with medical clinical practice guidelines and the rules of the health insurance provider.Conclusions: In coding, it is necessary to match the theory on the ICD-10, update the ICD-10. It is necessary to understand the rules and provisions made by the insurer and the related guidelines and rules. Please be aware of every latest code update.

scholarly journals DRUG COST ANALYSIS ON NATIONAL HEALTH INSURANCE ERA IN HEALTH SUPPORT FACILITIES

2017 ◽  
Vol 10 (2) ◽  
pp. 119
Author(s):  
Satibi Satibi ◽  
Dewa Ayu Putu Satrya Dewi ◽  
Atika Dalili Akhmad ◽  
Novita Kaswindiarti ◽  
Dyah Ayu Puspandari
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Health Insurance ◽  
National Health Insurance ◽  
Drug Cost ◽  
National Health ◽  
Health Facilities ◽  
Drug Costs ◽  
Average Percentage ◽  
Primary Health

Objective: In national health insurance (JKN) era, pharmacy can play roles in the form of behind refer pharmacies, or networking pharmacy and clinic pharmacy pratama. Behind refer pharmacies drug cost can be claimed directly to BPJS, meanwhile for the other type of pharmacy have to negotiation first with the primary health care. Drug cost variations in the JKN era affect the profitability of the business pharmacies. This research aims to the drug percentage charges against capitation and variety of drug costs.Methods: This research is analytic observational cross-sectional. This research uses secondary data from a JKN prescription patient. This research was conducted on 6 affiliated pharmacies, 6 networking pharmacies, and 7 clinical pharmacy pratama in DIY. The sampling in this research is by purposive with 8.430 prescriptions. Data drug costs JKN era was analyzed by descriptive statistics and comparative test (Kruskal Wallis test).Results: The result showed that average percentage of drug costs for capitation fee in the networking pharmacy is 13.58% and primary health care is 15.91%. Pharmacy in JKN era has drug cost variations (p=0.000). Drug cost in JKN era depends on the pattern of play roles with the health facilities and BPJS. The average percentage of drug costs against capitation health facilities in networking pharmacy is lower than clinical pharmacy pratama.Conclusions: Drug costs in an era of JKN depending on the pattern of cooperation with health facilities pharmacies and BPJS. The average percentage of the cost of drugs to the pharmacy capitation health facilities in networking lower than clinic pharmacy pratama. Differences in drug costs JKN era influenced by the long days of drug administration, the number of prescription sheets, margin.Keywords: Drug cost analysis, National health insurance (JKN), Pharmacy, Primary health care, Capitation.

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