A Critical Evaluation of the JKN Claims Process Implementation at Rasyida Kidney Specialty Hospital, Medan

Abstract

Quality of claims affects the cash flow of the hospital. Pending claims and disputes cause a cost burden for the hospital. The purpose of this study was to evaluate the JKN claim process at Rasyida Kidney Specialty Hospital. The research method is qualitative with triangulation testing. Results show that JKN Claim Submissions are submitted on time. The average percentage of compliant claims is 98%, while pending claims are 0.44%. The most pending outpatient claim cases in 2023 were diagnosis codes outside the hospital's specialty (80 cases). Meanwhile, the most pending inpatient claim cases were related to confirmation of the main diagnosis coding/reselection (17 cases). In conclusion, human resources are sufficient, money is allocated through a separate budget, materials still require accuracy in terms of completeness and content suitability, methods are aligned with regulations, and machines need special attention regarding server downtime. The processes of planning, organizing, actuating, and controlling are conducted routinely. The timeliness of claim submission adheres to period 2. The verification results have not yet reached 100%, and recurring pending claims still occur monthly.