Hospital Characteristics Determining Indonesian Case Base Groups Claim Rates

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