Hospital Characteristics Determining Indonesian Case Base Groups Claim Rates


Warsi Maryati, Novita Yuliani, Anton Susanto, Aris Octavian Wannay, Ani Ismayani Justika

 

Faculty of Health Science, Universitas Duta Bangsa Surakarta

 

ABSTRACT

Background: In the case-mix system, diagnostic codes are used as the basis for classifying health service rates. The inaccuracy of diagnosis and action codes may change the Indonesian Case Base Groups (INA-CBGs) codes which will affect on claim rates. Additionally, hospital characteristics also contribute to determining health service rates. This study aimed to describe the gap between hospital and INA-CBGs rates based on hospital characteristics.

Subjects and Method: This was a cross-sectional study conducted at hospitals X and Y in Surakarta, Central Java in 2020. A total of 100 inpatient medical records from two hospitals was selected for this study. Hospital X was a B-type private hospital, providing general medical services. Hospital Y was an A-type government hospital, providing specialized medical services. The study variables were hospital service and INA-CBGs claims. The data were reported descriptively.

Results: Hospital characteristics, including class, type, and hospital ownership, had different health service claim rates. Hospital X had lower claim rates in 26 (52%) documents and higher claim rates in 24 (48%) documents than the actual hospital service rates. The total tariff of IDR 309,378,300 for services was claimed IDR 263,296,400 by BPJS based on INA-CBGs rate. A negative difference IDR 46,081,900 was obtained at hospital X. Hospital Y had lower claim rates in 18 (36%) documents and higher claim rates in 32 (64%) documents than the actual hospital service rates. The total tariff of IDR 160,587,531 for services was claimed IDR 260,321,400 by BPJS based on INA-CBGs rate. A positive difference IDR 99,733,869 was obtained at hospital Y.

Conclusion: There was a gap in rates between hospitals and the accuracy of the diagnosis coded by INA-CBGs tariff policy. Private B-type hospitals, providing general medical services, received smaller claims and government type-A hospitals, providing specialized medical services received higher claims, than the actual service tariff.

Keywords: INA-CBGs, characteristics, hospital, rates, tariff

Correspondence: Warsi Maryati. Faculty of Health Science, Universitas Duta Bangsa Surakarta. Jl. K.H. Saman­hudi No. 93 Sondakan, Laweyan, Surakarta, Central Java. Email: warsi­maryati­@udb.ac.id. Mobile: +6285219103638

DOI: https://doi.org/10.26911/the7thicph.04.33

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