Upaya Pencegahan Perbedaan Diagnosis Klinis dan Diagnosis Asuransi dengan Diberlakukan Program Jaminan Kesehatan Nasional (JKN) dalam Pelayanan Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS Kesehatan) Studi di RSUD Kota Semarang

Abstract

Universitas Diponegoro Program Pascasarjana Program Studi Magister Ilmu Kesehatan Masyarakat Konsentrasi Administrasi Rumah Sakit 2016 ABSTRAK Faik Agiwahyuanto Upaya Pencegahan Perbedaan Diagnosis Klinis dan Diagnosis Asuransi dengan Diberlakukan Program Jaminan Kesehatan Nasional (JKN) dalam Pelayanan Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS Kesehatan) Studi di RSUD Kota Semarang xix + 153 halaman + 3 tabel + 16 gambar + 8 lampiran RSUD Kota Semarang mengalami tren kenaikan persentase perbedaan diagnosis klinis dan asuransi. Apabila hal ini terus berlanjut dapat mengarah pada upcoding (fraud). Tujuan penelitian ini adalah untuk menjelaskan proses terjadinya perbedaan diagnosis klinis dan diagnosis asuransi di rumah sakit dalam pelaksanaan Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan. Penelitian menggunakan metode kualitatif. Informan utama yaitu dokter jaga Instalasi Gawat Darurat (IGD), dokter spesialis bedah, dan dokter spesialis penyakit dalam, sedangkan informan triangulasi yaitu Direktur rumah sakit, verifikator rumah sakit, dan Kepala Unit Rekam Medis. Hasil wawancara mendalam dengan para informan dilakukan analisis isi untuk mendapatkan proses perbedaan diagnosis klinis dan diagnosis asuransi yang mengarah pada upcoding. Berdasarkan jawaban dari indepth interview telah terjadi perbedaan diagnosis klinis dan diagnosis asuransi di RSUD Kota Semarang. Penyebab perbedaan karena perbedaan diagnosis dan tindakan medis standar pelayanan medis dokter di RS dengan standar INA-CBGs. Untuk mencegah perbedaan diagnosis klinis dan asuransi, maka RSUD Kota Semarang sudah membentuk tim verifikator internal rumah sakit dan Clinical Micro System Team. Komite medik juga berperan membantu untuk membantu meminimalisir kejadian upcoding yaitu dengan memperbanyak jenis Clinical Pathway sebagai acuan bagi dokter untuk mendiagnosa dan menentukan jenis tindakan pada pasien. Perbedaan diagnosis klinis dan diagnosis asuransi harus segera diselesaikan untuk mencegah terjadinya upcoding dan kerugian RS. Upaya pencegahan perbedaan tersebut dengan menambah petugas dan pelatihan koding, membuat dan memperbanyak algoritma clinical pathway, pembentukan tim Clinical Micro System, dan monitoring dan evaluasi pelayanan medis. Kata kunci : Diagnosis Klinis, Diagnosis Asuransi, Koding, INA-CBGs, BPJS Kesehatan, JKN Kepustakaan: 84 (1992-2015) Diponegoro University Faculty of Public Health Master’s Study Program in Public Health Majoring in Hospital Administration 2016 ABSTRACT Faik Agiwahyuanto Efforts to Prevent Differences between Clinical and Insurance Diagnosis after Implementing the National Health Insurance Program in Services of Healthcare and Social Security Agency (Health BPJS) Study at Semarang City Public Hospital xix + 153 pages + 3 tables + 16 figures + 8 appendices Percentage of clinical and insurance diagnosis differences at Semarang City Public Hospital tended to increase. If this condition remained, it would lead to upcoding (fraud). The aim of this study was to explain a process of clinical and insurance diagnosis at a hospital in the implementation of Healthcare and Social Security Agency (Health BPJS). This was a qualitative study. Main informants consisted of doctors at an emergency room, surgeons, and internists. Informants for triangulation purpose consisted of a Hospital Director, a hospital verifier, and a head of Medical Record Unit. Data were analysed using content analysis. The results of this research showed that there were any differences in clinical and insurance diagnosis at Semarang City Public Hospital. The cause of these differences was due to differences in diagnosis and medical treatment between medical service standard of doctors at the hospital and a standard of INA-CBGs. To prevent the differences of clinical and insurance diagnosis, the Semarang City Public Hospital had formed an internal verifier team of the hospital and a Clinical Micro System team. A medical committee had a role to minimise the occurrence of upcoding by multiplying kinds of Clinical Pathway as a reference for doctors in diagnosing and determining kinds of treatments for patients. The differences of clinical and insurance diagnosis must be equated to prevent the occurrence of upcoding and disadvantage of the hospital. Efforts to prevent these differences are by adding officers, training coding, making and multiplying algorithm of clinical pathway, forming a team of Clinical Micro System, and monitoring and evaluating medical services. Keywords : Clinical Diagnosis, Insurance Diagnosis, Coding, INA-CBGs, health BPJS, NHI Bibliography: 84 (1992-2015)