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Faktor-faktor yang berhubungan dengan kepuasan provider terhadap proses klaim PT. Easco Medical 2009
Cynthia Valianty; Pembimbing: Wachyu Sulistiadi; Penguji: Dumilah Ayuningtyas, Bagus Satriya
S-5842
Depok : FKM-UI, 2009
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Tri Oktaviani; Pembimbing: Pujiyanto; Penguji: Eddy Setiawan
S-5915
Depok : FKM-UI, 2010
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Vera Wahyuni Ulandari; Pembimbing: Mardiati Nadjib; Penguji: Vetty Yulianty Permanasari, Atmiroseva
Abstrak:
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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.
S-11455
Depok : FKM-UI, 2023
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Shamim Thahir Ahmad; Pembimbing: Kurnia Sari; Penguji: Mardiati Nadjib, Edu Parningotan Aritonang
Abstrak:
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Durasi penyelesaian klaim menjadi indikator penting dalam menilai efisiensi pelayanan asuransi, terutama pada produk santunan harian rawat inap. Keterlambatan dalam proses klaim dapat menurunkan kepuasan dan kepercayaan nasabah terhadap perusahaan asuransi. Penelitian ini bertujuan untuk menganalisis faktor-faktor yang berhubungan dengan durasi penyelesaian klaim santunan harian rawat inap di PT. X berdasarkan data tahun 2023–2024. Penelitian menggunakan desain cross-sectional dengan pendekatan kuantitatif dan memanfaatkan data sekunder sebanyak 299 klaim. Analisis dilakukan secara univariat dan bivariat menggunakan regresi logistik ordinal. Hasil menunjukkan bahwa sebagian besar klaim diselesaikan dalam waktu 6–14 hari (39,1%) dan 0–5 hari (37,5%). Terdapat dua variabel yang memiliki hubungan signifikan secara statistik terhadap durasi klaim, yaitu asal daerah dan kelengkapan dokumen. Peserta dari luar Pulau Jawa cenderung mengalami durasi klaim lebih lama, sedangkan klaim dengan dokumen lengkap memiliki peluang yang jauh lebih besar untuk diselesaikan dalam waktu singkat. Empat variabel lainnya—sebab dirawat, jenis rumah sakit, nominal klaim, dan riwayat pengajuan sebelumnya—tidak menunjukkan hubungan signifikan namun memiliki kecenderungan praktis yang relevan.
The duration of claim settlement is an important indicator in assessing the efficiency of insurance services, particularly for hospital daily cash benefit products. Delays in the claim process may reduce customer satisfaction and trust in insurance companies. This study aims to analyze the factors associated with the duration of claim settlement for hospital daily cash benefits at PT. X based on 2023–2024 data. A cross-sectional design with a quantitative approach was used, utilizing secondary data from 320 claims. The analysis was conducted using univariate and bivariate methods with ordinal logistic regression. The results showed that most claims were settled within 6–14 days (39.1%) and 0–5 days (37.5%). Two variables showed statistically significant relationships with claim duration: region of origin and completeness of documents. Participants from outside Java Island tended to experience longer claim durations, while claims submitted with complete documents had a significantly higher likelihood of being processed more quickly. The other four variables—reason for hospitalization, hospital type, claim amount, and claim history—were not statistically significant but showed relevant practical trends.
The duration of claim settlement is an important indicator in assessing the efficiency of insurance services, particularly for hospital daily cash benefit products. Delays in the claim process may reduce customer satisfaction and trust in insurance companies. This study aims to analyze the factors associated with the duration of claim settlement for hospital daily cash benefits at PT. X based on 2023–2024 data. A cross-sectional design with a quantitative approach was used, utilizing secondary data from 320 claims. The analysis was conducted using univariate and bivariate methods with ordinal logistic regression. The results showed that most claims were settled within 6–14 days (39.1%) and 0–5 days (37.5%). Two variables showed statistically significant relationships with claim duration: region of origin and completeness of documents. Participants from outside Java Island tended to experience longer claim durations, while claims submitted with complete documents had a significantly higher likelihood of being processed more quickly. The other four variables—reason for hospitalization, hospital type, claim amount, and claim history—were not statistically significant but showed relevant practical trends.
S-12000
Depok : FKM-UI, 2025
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Mega Dwi Rahayu; Pembimbing: Atik Nurwahyuni; Penguji: Pujiyanto, Ina Hirina
Abstrak:
Pada tahun 2014, BPJS Kesehatan memiliki angka rasio klaim mencapai 104,73% sedangkan di BPJS Kesehatan Kantor Cabang Depok memiliki angka rasio klaim lebih dari 100% setiap bulannya pada tahun 2015. Kondisi ini mengartikan bahwa biaya klaim yang dikeluarkan lebih besar daripada pendapatan premi yang diterima. Rawat Inap Tingkat Lanjut menjadi salah satu jenis pelayanan yang menerima biaya klaim paling besar untuk pemanfaatan pelayanan kesehatan. Penelitian ini bertujuan untuk menguji faktor-faktor yang berhubungan dengan besaran klaim rawat inap tingkat lanjut peserta Jaminan Kesehatan Nasional BPJS Kesehatan Kantor Cabang Depok Periode September 2014-September 2015. Penelitian ini bersifat kuantitatif deskriptif dengan desain studi crosssectional. Data yang digunakan berasal dari data sekunder register klaim. Hasil penelitian menunjukkan bahwa umur, lama hari rawat, diagnosis penyakit, severity level, kelas perawatan, tipe rumah sakit, jenis kepesertaan memiliki hubungan yang signifikan dengan besaran klaim rawat inap tingkat lanjut (p=0,0005), sedangkan jenis kelamin tidak ditemukan memiliki hubungan yang signifikan dengan besaran klaim rawat inap tingkat lanjut (p=0,579). Variabel yang paling berhubungan dengan besaran klaim rawat inap tingkat lanjut adalah variabel severity level 3. Kata Kunci: Besaran Klaim; Rawat Inap Tingkat Lanjut; Jaminan Kesehatan Nasional
In 2014, BPJS Kesehatan have claims ratios reached 104.73% while in BPJS Kesehatan Depok have claims ratios more than 100% per month in 2015. This condition means that the cost of claims incurred is greater than the premium income be accepted. Secondary Care Inpatient is one of the types of health services that receive the most claim costs for the utilization of health services. This research aims to examine the factors associated with the number of claims secondary care inpatient of participants National Health Insurance in BPJS Depok period September 2014- September 2015. This research is quantitative descriptive and applied cross-sectional design. Data were collect from secondary source, for example claims register data. The results showed that the age, length of stay, diagnosis of disease, severity level, care class, hospital type, the type of membership has a significant correlation with the number of the secondary care inpatient claims (p = 0,0005), whereas gender was not found to have a significant correlation with tthe number of the secondary care inpatient claims (p = 0,579). The variables most associated with the number of the secondary care inpatient claims are variable severity level 3. Keywords: Claims, Secondary Care Inpatient; National Health Insurance
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In 2014, BPJS Kesehatan have claims ratios reached 104.73% while in BPJS Kesehatan Depok have claims ratios more than 100% per month in 2015. This condition means that the cost of claims incurred is greater than the premium income be accepted. Secondary Care Inpatient is one of the types of health services that receive the most claim costs for the utilization of health services. This research aims to examine the factors associated with the number of claims secondary care inpatient of participants National Health Insurance in BPJS Depok period September 2014- September 2015. This research is quantitative descriptive and applied cross-sectional design. Data were collect from secondary source, for example claims register data. The results showed that the age, length of stay, diagnosis of disease, severity level, care class, hospital type, the type of membership has a significant correlation with the number of the secondary care inpatient claims (p = 0,0005), whereas gender was not found to have a significant correlation with tthe number of the secondary care inpatient claims (p = 0,579). The variables most associated with the number of the secondary care inpatient claims are variable severity level 3. Keywords: Claims, Secondary Care Inpatient; National Health Insurance
S-9028
Depok : FKM-UI, 2016
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Ekaning Wedarantia; Pembimbing: Wachyu Sulistiadi; Penguji: Atik Nurwahyuni, A. Nandi Wahyu
Abstrak:
Penelitian ini bertujuan untuk menguji faktor-faktor yang berhubungan dengan utilisasi (besaran klaim) rawat inap tingkat lanjutan peserta lansia di PT Askes (Persero) Kantor Cabang Utama Jakarta Selatan tahun 2012 dengan menggunakan desain studi cross sectional. Teknik pengumpulan data dilakukan dengan mengisi daftar isian dari data sekunder yang berupa data register klaim. Diagnosis, lama hari rawat, jenis rumah sakit, dan kelas perawatan mempunyai hubungan yang signifikan dengan utilisasi (besaran klaim) rawat inap tingkat lanjutan, masing-masing dengan p-value 0,009, 0,001, 0,001 dan 0,001. Umur, jenis kelamin dan status kepesertaan tidak ditemukan hubungan yang signifikan dengan utilisasi (besaran klaim) rawat inap tingkat lanjutan.
The purpose of this research is to examine factors associated with utilization (claim) of elderly’s secondary care inpatient at PT Askes (Persero) primary branch office at South Jakarta n 2012. This research applied cross sectional design. Data were collected from secondary sources, for example claim register data. Diagnosis, length of stay, type of hospitals, and the class of treatment have significant relation with the utilization of secondary care inpatient, each with p-value 0,009; 0,001; 0,001 and 0,001. The result of the research shows that age, sex, and membership status do not have significant relation with the utilization of secondary care inpatient.
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S-7893
Depok : FKM-UI, 2013
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Subekti Yudianto; Pembimbing: Ronnie Rivany
S-2738
Depok : FKM-UI, 2002
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Evi Rahayu; Pembimbing: Wachyu Sulistiadi; Penguji: Nurwahyuni, Atik; Alviah, Evi
Abstrak:
Skripsi ini menggambarkan ekses klaim provider PT Asuransi X pada polis yang diterbitkan tahun 2012 periode pelayanan Januari 2012 ? Oktober 2013. Penelitian ini adalah penelitian cross sectional dengan desain deskriptif melalui pendekatan kuantitatif. Hasil penelitian dari data-data sekunder perusahaan dapat digambarkan bahwa biaya ekses klaim dipengaruhi oleh beberapa faktor, untuk faktor klasifikasi provider provider gold 50,20% dan 49.80 % dari total biaya ekses untuk provider silver. Faktor jenis kepesertaan ; karyawan 43.98%, pasangan 36.68% dan kepesertaan anak 19.35 % dari total biaya ekses klaim. Faktor berikutnya paket manfaat/pelayanan kesehatan yang terdiri dari rawat inap 51,43%, rawat jalan 29.05%, persalinan 13,19%, rawat gigi 6.24% dan paket manfaat kacamata 0.09% dari total biaya ekses klaim. Dari faktor kesesuaian isi polis terkait limitasi manfaat; rawat inap 52.96%, rawat jalan 23.75%, persalinan 15.02%, rawat gigi 8.16%, sedangkan limitasi manfaat kacamata 0.11% dari total biaya ekses klaim. Dari faktor pengecualian pada polis yang disebabkan karena: pengecualian diagnose 41.38%, pengecualian obat 31.27%, tindakan tidak indikasi 18.48%, pelayanan diluar tanggal efektif polis 7.13%, non medis 1.07% dan peserta yang tidak memiliki paket manfaat 0.66% dari biaya ekses klaim.
This study aims to describe the excess claim at PT Insurance X provider for policy issued in 2012 at January 2012 ? October 2013 Service Period. This study is cross sectional study with descriptive design through a quantitative approach. The result showed taken from Insurance Company secondary data describe that the excess claim cost influence by some factors, for classification of provider factor; gold provider reach 50.20% and 49.80% for silver provider from totally excess claim cost. Type of membership factor; employee 43.98%, couple 36.68% and children membership 19.35% from totally excess claim cost. The next factor of package benefit/health services that consist of inpatient 51.43%, outpatient 29.05%, maternity 13.19%, dental service 6.24% and package benefit of glasses 0.09% from totally excess claim cost. From the factor of compatibility policy content related to limitation of benefit inpatient 52.96%, outpatient 23.75%, maternity 15.05%, dental service 8.16% and package benefit of glasses 0.11% from totally excess claim cost. From the exclusion policy that caused by diagnose exclusion 41.38%, medicine exclusion 31. 27%, not indication treatment 18.48%, services out of effective date policy 7.13%, non medical 1.07% and member that have not benefit package 0.66% from totally excess claim cost.
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This study aims to describe the excess claim at PT Insurance X provider for policy issued in 2012 at January 2012 ? October 2013 Service Period. This study is cross sectional study with descriptive design through a quantitative approach. The result showed taken from Insurance Company secondary data describe that the excess claim cost influence by some factors, for classification of provider factor; gold provider reach 50.20% and 49.80% for silver provider from totally excess claim cost. Type of membership factor; employee 43.98%, couple 36.68% and children membership 19.35% from totally excess claim cost. The next factor of package benefit/health services that consist of inpatient 51.43%, outpatient 29.05%, maternity 13.19%, dental service 6.24% and package benefit of glasses 0.09% from totally excess claim cost. From the factor of compatibility policy content related to limitation of benefit inpatient 52.96%, outpatient 23.75%, maternity 15.05%, dental service 8.16% and package benefit of glasses 0.11% from totally excess claim cost. From the exclusion policy that caused by diagnose exclusion 41.38%, medicine exclusion 31. 27%, not indication treatment 18.48%, services out of effective date policy 7.13%, non medical 1.07% and member that have not benefit package 0.66% from totally excess claim cost.
S-8401
Depok : FKM-UI, 2014
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Glorianna Hutauruk; Pembimbing: Suprijanto Rijadi, Penguji: Pujiyanto, Jenal M Sambas
S-4655
Depok : FKM UI, 2006
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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Kristiara Amalia Fitria; Kurnia Sari; Penguji: Pujiyanto, Nurlitasari
Abstrak:
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Administrasi klaim merupakan proses penting yang dilakukan sebelum klaim dibayarkan oleh tertanggung. Komplain klien juga dapat mengganggu hubungan yang telah terjalin dengan pihak klien dan pihak perusahaan asuransi. PT Mitra Iswara & Rorimpandey (PT MIR) merupakan perusahaan pialang asuransi tertua di Indonesia yang bertindak atas nama tertanggung untuk memberikan nasihat dan kebijakan asuransi yang disesuaikan untuk mengelola risiko. Penelitian ini membahas faktor-faktor yang memicu komplain klien dalam administrasi klaim pada produk asuransi employee benefit di PT MIR. Penelitian ini menggunakan pendekatan kualitatif dengan desain studi kasus. Informan berjumlah 10 orang, yaitu Asisten Manajer Klaim dan Staf Analis Klaim PT MIR, serta Klien PT MIR. Hasil penelitian menunjukkan bahwa komunikasi, koordinasi, sumber daya manusia, kelengkapan dokumen klaim, serta pemahaman pemegang polis berperan dalam timbulnya komplain dalam proses adiministrasi klaim produk asuransi employee benefit di PT Mitra Iswara & Rorimpandey (PT MIR)
Claim administration is an essential step that must be completed before the insured pays the claim. Client complaints can also disrupt the relationship between the client and the insurance company. PT Mitra Iswara & Rorimpandey (PT MIR) is the oldest insurance brokerage company in Indonesia that acts on behalf of the insured to provide customized insurance advice and policies to manage risk. This study discusses the factors that trigger client complaints in administering claims on employee benefit insurance products at PT MIR. This study uses a qualitative approach with a case study design. There were ten informants: Claim Manager Assistant, PT MIR Claim Analyst Staff, and PT MIR Clients. The results showed that communication, coordination, human resources, claim documents' completeness, and policyholders' understanding played a role in the emergence of complaints in the claims administration process for employee benefits insurance products at PT Mitra Iswara & Rorimpandey (PT MIR).
S-11408
Depok : FKM-UI, 2023
S1 - Skripsi Pusat Informasi Kesehatan Masyarakat
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