Pandemi COVID-19 menghadirkan tantangan besar bagi sistem kesehatan di seluruh dunia, termasuk di Indonesia. Rumah Sakit yang ditunjuk Kementerian Kesehatan sebagai rujukan penyelenggara pelayanan pasien COVID-19 menghadapi tekanan finansial yang besar akibat peningkatan biaya operasional sedangkan jumlah kunjungan pasien non-COVID-19 menurun. Sesuai dengan kebijakan Peraturan Menteri Kesehatan Indonesia No. 59 Tahun 2016, pembiayaan pasien Penyakit Infeksi Emerging (PIE), termasuk COVID-19, dapat diklaim ke Kementerian Kesehatan. Dalam proses klaim, sering terjadi dispute akibat ketidaksesuaian antara BPJS Kesehatan dan berkas klaim yang diajukan oleh Rumah Sakit, yang yang dapat menjadi kendala pada kelangsungan pelayanan perawatan pasien dan menghambat arus kas Rumah Sakit. Tujuan penelitian ini adalah memetakan penelitian terkait manajemen dispute klaim COVID-19 Rumah Sakit di Indonesia tahun 2020 hingga 2022 di berbagai rumah sakit di Indonesia. Penelitian ini menggunakan metode scoping review yang disajikan secara naratif, kualitatif. Pencarian artikel dilakukan melalui basis data online (Semantics dan GARUDA), situs web (Google Scholar), dan perpustakaan organisasi (Universitas Indonesia). Terdapat 15 studi yang termasuk kriteria inklusi dan eksklusi dalam penelitian ini. Hasil penelitian menunjukkan persentase klaim pasien COVID-19 yang dispute di Indonesia (52%) lebih tinggi dibandingkan klaim yang dinyatakan sesuai (48%). Penyebab dispute klaim dipetakan menurut komponen struktur, proses, dan output. Faktor man dan material merupakan elemen mendasar yang paling mempengaruhi komponen struktur. Pada komponen proses, faktor pelaksanaan menjadi kendala utama dalam eksekusi manajemen klaim. Hasil identifikasi ini menjadi dokumentasi dan pembelajaran untuk pengelolaan klaim yang lebih baik ke depan bagi rumah sakit serta lembaga terkait dalam menangani situasi pandemi di Indonesia.
The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide, including in Indonesia. Designated hospitals appointed by the Ministry of Health in Indonesia to provide care for COVID-19 patients face substantial financial pressures due to increased operational costs, while the number of non-COVID-19 patient visits has declined. In accordance with the Ministry of Health Regulation No. 59 of 2016, the financing of patients with Emerging Infectious Diseases, including COVID-19, can be claimed from the Ministry of Health. However, in the claims process, disputes often arise due to inconsistencies between BPJS Kesehatan (the National Health Insurance) and the claim documents submitted by the hospitals. Disputed claims pose challenges to the continuity of patient care services and impede the hospitals' cash flow. The objective of this study is to map the research related to dispute management of COVID-19 patient claims in hospitals in Indonesia from 2020 to 2022 in hospitals across the country. This study utilizes a scoping review method presented in a narrative and qualitative manner. Article searches were conducted through online databases (Semantics and GARUDA), websites (Google Scholar), and organizational libraries (University of Indonesia). Fifteen studies met the inclusion and exclusion criteria for this research. The findings of the study indicate that the percentage of disputed COVID-19 patient claims in Indonesia (52%) is higher compared to claims that were deemed valid (48%). The causes of claim disputes were mapped according to the components of structure, process, and output. The "Man" and "Material" factors were identified as the fundamental elements that most influenced the structure component. In the process component, implementation factors emerged as the main obstacles in claims management execution. These identified results serve as documentation and a basis for learning to improve future claims management for hospitals and relevant institutions in handling the pandemic situation in Indonesia. |
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