Penelitian ini bertujuan untuk mengetahui faktor-faktor yang berhubungan dengan Penolakan Klaim Rawat Jalan Reimbursement Produk FSL di PT BCD periode Januari - Desember 2022 berdasarkan wawancara mendalam dan telaah dokumen. Selama periode bulan Januari – Desember 2022 klaim ditolak paling banyak dikarenakan klaim melebihi batas waktu pengajuan kelengkapan dokumen klaim sebesar 48,80% dari jumlah klaim yang ditolak pada produk FSL. Penelitian ini adalah penelitian kuantitatif dan kualitatif, dengan menggunakan teknik pengumpulan data melalui wawancara mendalam dan telaah dokumen. Hasil penelitian menunjukkan bahwa beberapa faktor yang berhubungan dengan penolakan klaim rawat jalan reimbursement meliputi SDM yang belum melakukan pelatihan, kurangnya kelengkapan dokumen klaim, SOP terkait penolakan klaim menurut pre-existing condition, waiting period, non-disclosure, not-meet criteria, policy exclusion, invalid claim, dan expired yang belum ada, kendala software terkait notifikasi pending gagal terkirim. Saran diperlukan pendidikan dan pelatihan mengenai klaim yang ditolak, membuat SOP secara spesifik mengenai klaim ditolak menurut pre-existing condition, waiting period, policy exclusion, non-disclosure, not-meet criteria, policy exclusion, invalid claim, dan expired, pembaharuan SOP claim, perbaikan dan pemantauan sistem secara berkala, menciptakan sebuah sistem konsultasi untuk nasabah.
The purpose of this study is to identify factors associated with Outpatient Reimbursement Claims Rejection for FSL Product at PT BCD during the period of January to December 2022 based on in-depth interviews and document analysis. During the period of January to December 2022, the highest number of rejected claims for the FSL product was due to claims exceeding the submission deadline, accounting for 48.80% of the total rejected claims. This research utilizes both quantitative and qualitative methods, with data collection techniques involving in-depth interviews and document analysis. The research findings indicate several factors associated with the rejection of outpatient reimbursement claims, which include insufficient training of human resources, incomplete claim documentation, absence of Standard Operating Procedures (SOPs) related to claim rejections based on pre-existing conditions, waiting period, non-disclosure, not meeting criteria, policy exclusion, invalid claims, and expired claims. Additionally, challenges related to software were identified, particularly regarding failed notification delivery for pending claims. Recommendations for improvement include the implementation of education and training on claim rejections, development of specific SOPs for claim rejections based on pre-existing conditions, waiting period, policy exclusion, non-disclosure, not meeting criteria, policy exclusion, invalid claims, and expired claims. Further suggestions involve updating the SOPs related to claims, periodic system improvement and monitoring, and establishing a consultation system for customers.
Vera Wahyuni Ulandari-Skripsi-FKM-Fulltext-2023.pdf ::