OVERVIEW OF POST-CLAIM VERIFICATION AND ADMINISTRATIVE AUDIT OF NATIONAL HEALTH INSURANCE AT SURYA HUSADHA GENERAL HOSPITAL, DENPASAR

Abstract

Post-Claim Verification and Administrative Audit by BPJS is a checking and evaluation process conducted after a health service claim has been submitted and paid by BPJS Health. This process reviews the claims that have been paid to ensure they comply with applicable regulations. RSU Surya Husadha Denpasar has conducted post-claim verification and BPJS JKN administrative audits. The results of these audits indicate that claims which have been paid need to be re-verified and audited because there are several components in the claim submissions that are lacking, causing them to fall into the category of non-compliant claims. This can trigger a refund of payments already made by BPJS, resulting in financial losses for the hospital. The research conducted at RSU Surya Husadha Denpasar used a quantitative descriptive method with a total sample of 259 post-claim verification files and JKN claim administration audits. Based on the results of the research and the discussion of post-claim verification and JKN administrative audits at RSU Surya Husadha Denpasar, it was found that the post-claim verification results for the National Health Insurance (JKN) conducted by BPJS at RSU Surya Husadha Denpasar showed that out of 18 post-claim verification files for July – September 2023, 6.9% did not meet the requirements, while 93.1% were compliant. The non-compliant files have been used to prepare an official report as a basis for compensating the excess claim costs that have been paid in the future. The results of the National Health Insurance claim administration audit conducted by BPJS Health at RSU Surya Husadha Denpasar showed that out of 15 claims administration audit files for July – September, 5.8% did not match the requirements, while 94.2% were compliant. The non-compliant files have been recorded in the minutes of the audit results as a basis for compensating the excess claim costs that have been paid in the future.