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Utilization Review pada Jaminan Kesehatan Nasional: Implementasi, Tantangan dan Komponen Essensial Ulandari, Luh Putu Sinthya; Indrayathi, Putu Ayu
Jurnal Ekonomi Kesehatan Indonesia Vol. 10, No. 2
Publisher : UI Scholars Hub

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Abstract

Indonesia has implemented the National Health Insurance (JKN) program since 2014; however, various forms of fraud continue to be found. According to regulations, BPJS Kesehatan, as the national social security agency, is required to conduct Utilization Review (UR) as an effort to control costs and improve the quality of healthcare services. The effectiveness of UR remains questionable due to several implementation challenges. This study aims to explore the implementation of UR, identify its challenges, and examine the essential components required for its effective implementation. The study was conducted in August 2023 using a qualitative approach through in-depth interviews. Samples were selected purposively and consisted of five key informants. Data were analyzed using thematic analysis. The results showed that all respondents had good knowledge of the UR concept. BPJS Kesehatan applies a retrospective method. The UR results vary, including trends or patterns of patient visits, the ten most frequent Case Base Groups (CBG), the ten most common procedures, and the ten cases with the highest funding for outpatient and inpatient services. BPJS Kesehatan also formulates recommendations based on the UR results. However, strong commitment from healthcare providers is required to implement improvements. The challenges faced by BPJS Kesehatan include limited time for conducting UR, the large number of healthcare facilities to be assessed, as well as conflicts and misunderstandings with patients. Regarding essential components, three key aspects are needed: human resources, technology, and standardized UR procedures.
Co-Authors Adhi, K.T. Anak Agung Sagung Istri Maradi Suryaningrat Anastasia Septya Titisari Benny Tjahjono Budiastri Citra Mutiarahati, Ni Luh Cokorda Bagus Jaya Lesmana, Cokorda Bagus Jaya Coratry Shovariah Premilga Desak Putu Yulita Kurniati Dinar Lubis Dinar Lubis Dyah Pradnyaparmita Duarsa Erma Pradnyani, Putu Fery Dwiyanto HARI MULYAWAN Hendrayani, Ni Wayan Ani I Gusti Ayu Agung Putri Krismayanthi I Ketut Suwiyoga I Ketut Tunas I Made Ady Wirawan I Made Artana I Nyoman Gede Budiana I Putu Ganda Wijaya I Putu Ganda Wijaya I Putu Ganda Wijaya Ilyas, Jaslis Istiana Marfianti Istiana Marfianti Ketut Suarjana Kolozsvari, Laszlo Robert Krismayani, Tika Krismayanti, Ni Kadek Ari Kurniati, Desak Putu Y Kurniawati, D.P.Y. Laszlo Robert Koloszvari Laszlo Robert Kolozsvari Luh Kadek Ratih Swandewi Luh Kadek Ratih Swandewi Luh Putu Sinthya Ulandari Luh Seri Ani Made Nopy Diah Sundari Manuaba, I.B.G. Fajar Megayanti, Ni Luh Komang Monika Sri Yuliarti Monika Sri Yuliarti, Monika Sri Murniati, Ni Nengah N.M.U. Dwipayanti Ngakan Putu Anom Harjana Ni Ketut Sutiari Ni Luh Saptiaryati Ni Made Ari Listiani Ni Made Mas Dwi Purwaningrat Ni Made Sri Nopiyani Ni Nengah Murniati Ni Nyoman Intan Widya Sari Ni Wayan Ani Hendrayani Ni Wayan Arya Utami, Ni Wayan Arya Nijyoti, Nitya Nirmala, Putu Nitya Nitya Nijyoti Pande Made Sri Rahayu Pande Putu Januraga Putu Dwiki Damadita Putu Inok Puspaeni Putu Nitya Nirmala Putu Novi Trisna Dewi R. A.T. Kuswardhani Rasmaya Niruri Rasmaya Niruri Rasmaya Niruri Rina Listryowati Rina Listyowati Rina Listyowati Rina Listyowati, Rina Rini Noviyani Sagun Chandra Yowani Santosa, Karina Samaria Sri Idayani Sri Idayani, Sri Suandana, Iwan Abdi Sundari, Made Nopy Diah Ulandari, Luh Putu S WIDARSA WIDARSA Wijaya, I Putu Ganda Yaslis Ilyas