ANALYSIS OF COMPLIANCE WITH THE INA- CBGS CLAIM PROCESS AT RACHMA HUSADA HOSPITAL: A MIXED-METHODS STUDY

Abstract

Background: The implementation of Indonesia's National Health Insurance (JKN) utilizes the Indonesian Case-Based Groups (INA-CBGs) prospective payment system, presenting significant challenges for hospital claim process compliance. RSU Rachma Husada, a Type C private hospital, has experienced issues including claim rejections and delays, potentially impacting financial stability.

Objective: This study aimed to analyze the compliance of the INA-CBGs claim process at RSU Rachma Husada and identify factors influencing compliance levels.

Methods: An explanatory sequential mixed-methods design was employed. The quantitative phase utilized a quasi-experimental one-group pretest-posttest design with 85 hospital staff. The qualitative phase involved in-depth interviews and focus group discussions with 9 Casemix team members.

Results: The educational intervention significantly increased staff knowledge (Z =-6.824, p < 0.001) and compliance (Z = -5.973, p < 0.001). However, the correlation between knowledge improvement and compliance enhancement was positive but weak (Spearman's r = 0.296, p = 0.006). Qualitative findings revealed key themes influencing compliance: varying staff reliability, inconsistent attending physician (DPJP) commitment to documentation, effectiveness of regulatory socialization, and challenges in coordinating complex cases.

Conclusion: While enhancing staff knowledge improves INA-CBG claim process compliance at RSU Rachma Husada, its impact is limited. Systemic factors, particularly DPJP commitment, documentation quality, communication effectiveness, and workload management, significantly influence overall adherence. A multifaceted approach addressing both knowledge gaps and contextual factors is necessary to optimize the INA-CBG claim process, reduce errors, and ensure the hospital's operational and financial sustainability within the JKN framework.