Suspension Claim Health Insurance Hospitalized Due to Incomplete

Medical Record

Agus Sarjono

, Endang Ruswanti

and Nia Puspita Haspari

and Kemala Rita Wahidi

Master of Management, Esa Unggul University, Jalan Arjuna Utara Number 9, Jakarta, Indonesia

Master of Hospital Administration, Esa Unggul University, Jalan Arjuna Utara Number 9, Jakarta, Indonesia

Faculty of Economy and Business, EsaUnggul University, Jakarta, Indonesia

Faculty of Law, Esa Unggul University, Jakarta, Indonesia

Keywords: Medical records, hospitalized patients, claims, procedures, drugs, identity.

Abstract: This study aims to determine the Influence of Medical RecordCompleteness (Data Identity, Improved Drug

Security and Certainty Procedure) Against Health InsuranceClaim Submission at RS. This type of research

includes an analytic survey with a causality approach. With this research,object data submission claims

patients sampled as many as 98 patients. Sources of data in the form of secondary data based on RS medical

records report of 2017 which is analyzed using Binary Logistic Regression. The results obtained that the

identity of the data significantly influences the submission of claims.Furthermore, the increase in drug

safety significantly affects claim submission,andlastly, the certainty of the procedure significantly affects

claim filing. The findings of researchers of the delay most claims are due to incomplete medical records,

especially data support, filling odontogram, identity data, doctor diagnosis and errors enter thecode.

Implications for hospital management in order to socialize standard operational procedure on completeness

of filling of the medical record to all providers of good care Doctor, nurse, midwife, nutrition,

physiotherapy, Pharmacy.

1 INTRODUCTION

National Health Insurance System (NHI) under

Law no. 40 The year 2004 is a compulsory Social

Health Insurance system in Indonesia. NHI is one of

the programs of the National Social Security System

(SJSN) through the Social Security Administering

Agency claim established on January 1, 2014, as

regulated in Law no. 24 2011. Health insurance that

is comprehensive for every Indonesian people is

realized through NHI program which is a

government program to make the people of

Indonesia can live healthy, productive, and

prosperous. Claim aims to realize the

implementation of ensuring the basic needs of

decent living for each participant or members of his

family. Implementation of the national social

security system based on the principle: 1) mutual

cooperation; 2) non-profit; 3) openness; 4) prudence;

and 5) accountability. (UU BPJS, 2011).

Hospitals as one health service facility have a

role important in achieving the goal of NHI which is

expected to provide efficient, effective, and

demanded services to provide appropriate health

information and produce accurate data in health

services, all of which can not be separated from the

important role of patient medical records. According

to the minister of health regulation, number

269/Menkes/Per/III/ 2008. Concerning Medical

Record is a file containing records and documents

about patient identity, examination, treatment, action

and other services that have been given to the

patient.

Health Insurance claims submissions for patients,

especially for new inpatients will be accepted what

if it meets the various conditions in accordance with

the claim law (2011), namely: 1) SEP (Letter of

Interest of Participants); 2) Inpatient Introduction

Letter; 3) Resume of hospitalization; 4) claim sheet;

5) evidence sheet of inpatient service; 6) receipts

and 7) other supporting results

The completeness of medical record documents

greatly affects the quality of disease statistics and

health problems, as well as in the process of

payment of health costs with INA CBGs software.

Incomplete medical records may indirectly reduce

2994

Sarjono, A., Ruswandi, E., Puspita Haspari, N. and Rita Wahidi, K.

Suspension Claim Health Insurance Hospitalized Due to Incomplete Medical Record.

DOI: 10.5220/0009948829943000

In Proceedings of the 1st International Conference on Recent Innovations (ICRI 2018), pages 2994-3000

ISBN: 978-989-758-458-9

the cost of claims based on INA CBGs software.

Based on the results of research Ulfah et al. (2011)

conducted at RSI Sultan Agung Semarang obtained

the result that the importance of medical record data

to smooth approval of Jamkesmas claims. Where Of

9 people with incomplete medical record documents

are all not approved of Jamkesmas claims, and from

the complete medical record records 52.9% are

approved by their Jamkesmas claim

Report from Karawaci Tangerang Hospital in

2016 showed that 8,793 (14.7%) of inpatients from

59,993 patients overall, from 8,793 inpatients there

were 296 (3.4%) patients with incomplete medical

record data. While in 2017 showed an increase in

hospitalized patients to 10,308 of 85,947 patients as

a whole, and from 10,308 inpatients there were 405

(3.9%) patients with incomplete medical record data.

Data at RS. Karawaci Tangerang in 2017 indicates

that the incompleteness of medical records data

mostly occurs at 1) The accuracy of patient identity

(name, medical record number, place of birth date,

sex) that is 37 patients (9%); 2) Increase of drug

safety (proper drug, correct dose, patient right,

proper document, timely and appropriate way of

giving) that is as many as 44 patients (11%); 3)

Certainty of procedure (date and time of action,

result of anamnesa, filling odontogram, diagnosis,

action management plan, physical and supporting

investigation, informed consent) that is 60 patients

(15%).

Also,a source in RS. Karawaci Tangerang 2015

shows hospitalized patients with claims of XYZ

claims 8,855 and 397 (4.4%) of pending claims, this

data increased in 2016 from 8,793 cases filed there

were 408 (4.6 %) claims in pending, as well as in

2017 increased claims in pending up to 445 (4.7%)

of the 9413 submitted cases.

The purpose of this research is to determine the

Influence of Medical Record Complete Patient

Inpatient health Insurance Against Claim

Submission. The contribution of research that is

expected as input for a hospital to improve health

service quality and as an evaluation to hospital

performance related to medical record matter.

The most important research motivation in this

study is the better completeness of RM data so that it

will increase the number of approved health

insurance claims that will ultimately affect the

smooth flow of cash flow and improvement of

health services.But, we have the limitation of this

research: Variable completeness of medical record

in this research is only limited to data identity

variables, drug security improvement and certainty;

This research only covers in Sari Asih Hospital

Karawaci Tangerang only with the number of

respondents is limited, so it is still possible to do

further development with the number of respondents

and research variables more.

2 RESEARCH METHOD

This type of research includes an analytic survey that

examines the existing thing without intentional

treatment to generate or cause a symptom or

condition (Notoatmodjo, 2010). The type of research

is causality. This research is done by the cross-

sectional approach, that is data collection of the

dependent variable and independent variable which is

done at the same time (Notoadmodjo, 2010). The

technique used in this study to determine the sample

size of the population is a systematic random

sampling technique (a simple random sample). Data

analysis used binary logistic regression analysis. The

flowchart of the research method showed in Figure 1.

Figure 1: Research Method

3 OPERATIONAL DEFINITION

OF VARIABLES

The variable in this research is the dependent

variable (Y) is the claim filing claim approval for the

Determine the

Simple Size

Suspension Claim Health Insurance Hospitalized Due to Incomplete Medical Record

2995

guarantee of the health care needs of members

health insurance itself. With the instrument in the

form of a questionnaire consisting of 9 indicators

with a nominal scale. While the independent

variable (X) is the completeness of the medical

record is a file containing records and documents

about identity, examination, treatment, action, and

other services that have been given to the patient. In

this study consisting of patient identity accuracy,

improvement of drug safety, the certainty of the

procedure. With a questionnaire instrument

consisting of 17 indicators with a nominal scale.

4 RESEARCH RESULT

The results of the research are shown in the

frequency distribution of patient medical record

completeness as follows:

Based on the above can be seen that the medical

record completeness variable consists of 3

Dimensions. The first is the data identity dimension

consisting of 4 indicators, the second dimension is

the improvement of drug safety consisting of 6

indicators, the third dimension is the certainty of a

procedure consisting of 7 indicators.

From the table, it can be seen that on the identity

data of 98 respondents there are 95 documents

complete medical records with 97% percentage

whereas incomplete medical record document there

3 with 3% percentage, i.e.2 files no place, birth date

and 1 file no gender.

Furthermore, for the improvement of drug safety

that there are 92 complete medical records document

with percentage 94% while incomplete medical

record document there 6 with the percentage of 6%,

that is, each of 2 files is not exactly patient, 2 files

have no proper document, and 2 files are not on

time.

Lastly, for the improvement of drug safety, there

are 86 medical record documents complete with

88% percentage whereas incomplete medical records

document there are 12 with 12% percentage that is 1

file there are no diagnosis and 11 files there is no

odontogram file

 Submission of Claim Health Insurance

approved 43% and not approved 57%. The

above table states that there are 56

unacceptable claims with 57%, whereas

approved

 Claims are 42% with 43% Cross-tabulation of

the completeness of

 medical record documents against claims

submission.

Based on the above table it is clear that RM

document is incomplete and not approved as much

as 16, RM document is incomplete and approved 0,

while RM complete document not approved 40 and

complete RM document approved 42.

4.1 Hypothesis Testing

Based on the above table the results of testing

individually or partially based on the above table

apart note that the value of wald on each variable of

19,470 (identity data), 14.303 (Improved Security of

drugs) and 23,000 (Certainty Procedure) and all sig

0.000 <0.05 (5 %), it can be concluded that the

accepted hypothesis is the data identity variable,

drug security, the certainty of the procedure partially

significant effect on the approval of the claim.

4.2 Discussion

4.2.1 Medical Record Compliance

Based on this research, data from 98 medical

record document samples are 82 complete medical

records document with the percentage of 83,6%,

while a document of incomplete medical record is

16 with percentage 16,4%. Medical records

according to the Indonesian Minister of Health

Regulation 269 / MENKES / PER / III / 2008 are

files containing records and documents on identities,

checks, medications, actions and other services that

have been provided to patients. Completeness of

medical record is very important because a complete

medical resume in addition to maintaining the

quality of medical records is also used for the

administration of insurance claims (Anggraini,

2013) .The results of this study in line with research

conducted by Ulfahet al. (2011) obtained data from

94 samples 85 complete medical record document

with the percentage of 90%, while incomplete

medical records document there are 9 with the

percentage of 10%.

According to the researchers, the following

matters are factors for the incompleteness of the

medical record document in this study, because the

patient did not fill in the data on the date of birth and

sex because the patient forgot to fill in the

consultation form. Also seen from the form filling

data supporting results that have been prepared but

not yet complete for example the diagnosis of

febristhypoid must be equipped with blood test

results, Tuberculosis equipped with sputum

examination and thorax photo.

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4.2.2 Claim Submission

Based on research at Karawaci Hospital of

Tangerang, the researcher obtained the result of the

claim which has been approved by independent

verifier of 98 samples. There are 56 unacceptable

claims with 57% percentage, while the approved

claim is 42% with 43% percentage. Submission of

Claim Approval is the activity of the verification

process by the independent verifier to the

correctness of administration of responsibility of

service which has been executed by Hospital.

Complete claim requirements then the verification

process may be approved, the claim requirements

are incomplete then the verification process is not

approved and returned to the medical and financial

records to complete its administration based on the

results of its verification.

This research is in line with those done by Ulfah

et al. (2011), which are 9 people with incomplete

medical record documents, all of which are not

approved by Jamkesmas claim, and from the

complete medical record document, 52,9% are

approved by Jamkesmas claim.

According to the researchers can be seen that the

percentage of the approved 57% larger than the

approved is 42%, this is according to researchers

occur due to several factors. Of 56 unapproved

verifiers with 57% percentage, influenced by RM

incomplete document factor (no gender identity,

TTL, patient exact, proper document, odontogram

and diagnostic) and no physician's signature,

incompleteness as much as 16 data or 28.6%, then

because of diagnostic investigation result (thorac

examination and ct scan, blood test, urine

examination, therapy or medicine) data with

percentage 62.5% and because of coding rules there

are 5 data with percentage 8.9%. Based on the

number of factors affecting the unapproved claim,

the biggest factor affecting the claim is not approved

due to the incomplete investigation result

4.2.3 Influence Data Identity with

Submission of Health Assurance

Wald test results obtained wald value of 19.470

and p-value significance variable data identity of

0.000 <0.05 then reject H0. It can be concluded that

there is a significant influence on the data identity of

JS claim submission with the value of effect

coefficient which can be seen based on value (B) of

1.310.

The identity of medical record data is the

backbone of effectiveness and efficiency of medical

record system (WHO, 2002). The results of this

study are in line with research conducted by Ulfahet

al. (2011) where as many as 9% of unapproved

BPJS claims are affected by the incompleteness of

the RM document including the medical resume

containing the identity of the health insurance

patient data.

According to the researcher, the identity of the

data is the recording of all information about the

evidence of a person/Individual to establish and

equalize the information with a person. The

completeness of the document identity data greatly

affects the quality of RM data which will be

included in a medical resume which is the

requirement of health insurance claim submission

According to search results, there was no data of

2% sex and 2% on the place of birth date on the

medical record because the patient did not fill out

the data on the consultation form and the TPP officer

did not ask.

Whereas according to WHO (2002) the identity

of patient data must be written clearly and truthfully

because the truth of patient identity makes it easier

for hospital staff to:

 To find out information about patients

whenever they come to health services

 To connect the arrival of the previous patient

or the presence of outpatients and inpatients to

enter the targeted health service by using the

medical record number

 To find the correct medical record if more

than one patient has the same name

Given the importance of the patient's data

identity in the RM, it is expected that the health

worker should be more proactive in assisting the

completeness of the patient's medical records file by

asking carefully and carefully about the patient's

identity and should ensure that the questions asked

are clear and understandable by the patient. Also,

there is cooperation between each section to

complete the filing of patient medical record files.

4.2.4 Effect of Improving Drug Security

with Submission of claims

Wald test results obtained wald value of 14.303

and indigo p-value significance of drug safety

improvement variables of 0.000 '<0.05 then rejected

H0 which proves that there is a significant effect of

increasing the safety of drugs against claims BPJS

with the value of the coefficient of influence can be

seen by value ( B) of 0.648.

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Increased drug safety means to know precisely

the drug, proper dose, patient right, proper

document, a timely and appropriate way of

administration (WHO, 2002).According to

Permenkes no 28 of 2014 states that any reports of

drug services reported in BPJS claims should

contain data on drug use against individuals is claim

participants.

The results of this study are in line with previous

research conducted by Feriawati P and Kusunat AP

(2015) on factors of delay in claiming claim in

Bhayangkara Hospital Semarang, found documents

that are not equipped or about 5.7% of the total

samples included are incompleteness medical

resume data.

According to the research results of researchers

on incomplete RS documents (2%), right patient

(2%) and timely (2%) this happens because there are

still health workers who are not disciplined in

identifying patients with identification bracelet so

they can not be inputted in RM data. Also, because

of time limitations in the collection of RM

documents

According to the researcher, drug safety

improvement becomes part of file verification in

claim filing that is in the verification stage of

hospital service included in a medical resume. If the

hospital can meet the completeness of documents,

the faster the process of disbursement of claims.

4.2.5 The Influence of Certain Procedures

with Submission of Claims

Wald test results obtained wald value of 23,000

and value of p-value significance of the certainty of

the procedure of 0.000 '<0.05 then reject H0 which

proves that there is a significant influence the

certainty of the procedure against the approval of

claims with the value of coefficient of influence can

be seen based on value (B) of 0.893.

The certainty of the procedure is the certainty of

action seen from the date and time of action, the

results of the history, the filling of the odontogram,

the diagnosis, the plan of action management, the

investigation and the physical, informed consent

(WHO, 2002).

This result is in line with previous researchers

conducted by Ulfahet al. (2011) where as many as

9% of unapproved claim claims are affected by the

incompleteness of RM documents including most of

which are medical resumes containing diagnoses and

investigation results.

The researcher found that odontogram filling was

incomplete 11%. This is because the dentist feels

like overwhelmed because he has so many patients

can not make or prepare medical record records

odontogram in practice. While 1% (1 medical

record) there is no doctor diagnosis of the matter

because the doctor did not write the diagnosis or the

doctor's writing is unreadable.

The medical recorder will return to the polyclinic

through a nurse. However, if this is still allowed (the

doctor still does not write the diagnosis), then the

medical recorder will take back the medical record

and not coding the diagnosis. Medical record

officers rarely reprimand doctors for being reluctant

and have no binding rules such as Standard

Operation Procedure (SOP).

According to the researcher, the certainty of the

procedure becomes the condition of the

completeness of the medical record contents which

in the medical record should contain sufficient

information about the patient, giving the reason in

applying the diagnosis and equipment and recording

the entire examination result. Services obtained by

the patient during treatment or medical treatment.

The certainty of procedure becomes one of these

sections of medical record files that have

administrative value in claims due to their contents

concerning actions based on authority and

responsibility as medical and paramedical personnel

in achieving health service goals. Therefore the

more complete the document,the faster the

submission of claims BPJS.

4.2.6 Medical Record Completeness

Relation (Data Identity, Improvement

of Drug Security, Certainty of

Procedure) with Claim Submission of

Claim

Medical Record Completeness Relation (Data

Identity, Improvement of Drug Security, Certainty

Procedure) together can be seen from omnibus test

obtained Sig.Model value of 0.000 <0.05 so it is

concluded that the medical record completeness

variable (X) used, together affect the claim health

insurance submission (Y).

Medical records according to the Indonesian

Minister of Health Regulation 269 / MENKES /

PER / III / 2008 are files containing records and

documents on identities, checks, medications,

actions and other services that have been provided to

patients. The completeness of the medical record is

of great importance as a complete medical resume in

addition to maintaining the quality of medical

records is also used for the administration of

insurance claims (Anggraini, 2013).

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Medical records are an important part of patient

management. RM is important for doctors and

medical officers as the patient's medical

documentation correctly in addition to the

importance of medical records due to two things

namely; The first is to help patients evaluate

appropriately and plan treatment protocols. Second,

the legal system relies primarily on documentary

evidence in case of medical negligence. Therefore,

medical records must be properly written and

maintained to serve the interests of the physician as

well as his patients (Amit, Bali et al., 2011).

Referred to the completeness of medical records in

this study is the completeness of medical record

documents regardingthe accuracy of data identity,

improvement of drug safety and certainty of

procedures.

According to Ilyas (2013), the claim is a request

of one of the two parties having a bond so that his

rights are fulfilled. One of the two parties who

commit the bond will file his/her claim to the other

party in accordance with the agreement or policy

provision mutually agreed upon by both parties. In

this case, the claim is claimedhealth insurance with

one of the requirements is the completeness of the

medical record.

The results of this research are in line with

previous research conducted by Ulfah et al. (2011)

conducted at RSI Sultan Agung Semarang obtained

the result that the importance of medical record data

to the smooth submission of claims. Where Of 9

people with incomplete medical record documents

all are not approved by claims, and from complete

medical records 52.9% are approved by health

insurance claims. In his research Ulfah, et al. (2011)

stated that SOP of claim submission already exists,

but still not according to the procedure, thepatient

often does not bring requirement, delay of claim

process health insurance happened partly because of

some of the data incomplete, often inconsistent

name of the patient.

Feriawati (2015) states that an incomplete DRM

file such as the absence of a doctor's signature and

the doctor's bright name, the diagnosis has not been

filled / not yet written / the diagnostic code, the

history of the course of the disease has not been

completely filled. This will lead to a delay in the

process of submitting a claim to health insurance.

Another study by Changfu (2013) states that the

accuracy and appropriateness of medical record

document information will help the Hospital in

making claims to the insurance provider against the

cost of services that have been issued by the

Hospital. The Hospital will easily obtain fees for

compensation in accordance with the applicable

rules and agreements. This is because a complete

and accurate medical record document can meet all

legal procedures, regulations and audit requirements.

According to the researchers, the completeness

of the medical record document is one of the

supporting in improving the quality of hospital

health services. Proper and correct documentation

will affect the quality of medical records as well as

ongoing medical records and patient care.

Completeness of DRM also affects the smoothness

of the insurance claim process both government and

private insurance to know the amount of payment to

be paid, from the information contained in the

medical record. In this research, the incompleteness

of medical record documentation is because there is

no diagnosis by doctors, incomplete data such as

evidence of laboratory results etc, and errors enter

the code.

Given the importance of medical record

completeness in the effort to file XYZ claim

therefore health officers should be more accurate in

collecting files so that there is no shortage of files in

the previous section, especially data completeness

investigation so that at the time of claiming can be

faster than that remind doctors to enforce diagnosis

according to the standard of medical service

according to the specialization of the case and

complete the complete and correct resume as well as

training for medical record officer according to

coding theory that is book of ICD-10 volume 2 in

order to meet the coding performance accuracy>

84%, and medical record officers need to perform

quantitative and qualitative analysis.

5 RESEARCH FINDING

The findings of research results based on

interviews and observations using various data

analysis can be expressed as follows: (1) It causes

incomplete medical records file that is: (a) The

patient did not fill out the data on the consultation

form and the TPP officer did not ask (b) Health

workers are not disciplined in identifying patients

with identification bracelet so it cannot be inputted

in medical record (c) Limitations of time in

document collection medical record: (2) The thing

that causes the claim submission is not approved (a)

Medical record documents are not complete and

there is no signature of the treating physician (b)

Completeness of investigation results such as

laboratory results, Rontgen photo and therapeutic

results, are given (c) Error enter the code

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6 CONCLUSIONS

There is significant influence between the

Medical Record of Inpatient Patients of BPJS on

Claim Submission at RS. Sari Asih Karawaci

Tangerang Year 2017. This research has the

implications:

 To the hospital management to conduct

socialization of SOP (Standard Operational

Procedure) complete medical record 1 X 24

hours after completion of service to all

doctors, nurses, midwives, nutrition,

physiotherapy, pharmacy and socialization

about the patient requirement of health

insurance medical records can be on time.

 Attending or conducting training or seminar

seminars on the completeness of the medical

record for perfection in the service as well as

for law and claim

 Creating service excellence training for all

officers at registration officer

 Make the Internal Verifier Worker, who will

perform the completeness check of the

BPJSclaim submission requirements

For subsequent research, We have the

suggestions. They are:

 Conducting socialization of SOP (Standard

Operating Procedure) on the filling of

Medical Record.

 Revised Standard Operating Procedure claims

as a guide in carrying out routine work.

 Regular evaluation of the incompleteness of

medical records file at Sari Asih Karawaci

Hospital Tangerang.

 Increase the power for the hospital's Internal

Verifier, who will perform the initial

verification before submitting to health

insurance.

 Conduct routine evaluation in the

implementation of health insurance services

ACKNOWLEDGEMENTS

The researchwas supported by Master of

Management, Faculty of Economy and

Business,Faculty of Law, Esa Unggul University.

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