The importance of operational audit in identifying cost variance of healthcare services in BPJS Era

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The implementation of BPJS social insurance since 2014 has had a significant impact on healthcare services in hospitals. The impact is mainly seen in the change of financing for health services as before BPJS era it was very varied. Before the BPJS era the package of health service benefits was still very dependent on the organizing body, there were still costs that were not guaranteed (exclusion of benefits), limitation of services (limitation benefit), even the necessity of paying the difference in bills (cost sharing). These conditions allow for partial membership, the provision of different benefits, thus indicating discrimination in healthcare services.

Entering the new era of BPJS that has been running for 6 years, the shortcomings of the previous era were overcome by the principles of mutual cooperation, non-profit, openness, prudence, accountability, mandatory participation, and the results of the management of social security funds entirely for the development of the program and for the interest of the participants. It certainly cannot be separated from the existence of an equal membership fee payment system and the existence of INA-CBG package payment system based on the illness suffered by the patient.

Hospitals will receive payments based on INA-CBG rates, which are the average costs spent by a disease diagnosis group, so that all hospitals that implement BPJS will get paid according to the patient’s disease diagnosis. The INA-CBGs payment model has 1,077 tariff groups consisting of 789 inpatient group codes and 288 outpatient group codes. Furthermore, this payment model also guarantees that hospitals provide quality clinical care, not ignoring the needs of patients or simply meeting the agreed treatment rates.

The INA-CBG package method will prosper the healthcare service provider if there is control, supervision and evaluation in the operation of payment system at the hospital. Hospitals can suffer a significant loss if there is no control over the agreed patient care rates with the actual patient care rates, this causes variance in the cost of healthcare. The negative cost variance is lower than the actual cost of INA-CBG package, while the positive cost variance means the opposite. Therefore, it is very important to control funding in the continuity of hospital operations and require an operational audit.

An operational audit is conducted to assess and to provide information to hospital management, especially information about the existence of variance in the cost of healthcare services. For example, several diagnoses of diseases with the highest cost variance such as chronic ischemic heart, cerebral infarction, end-stage kidney disease and type 2 diabetes mellitus often experience payment differences between INA-CBGs packages and actual payments that can reduce the effectiveness and efficiency of services and can even harm hospitals and patient. This can be monitored and evaluated using regular and periodic operational audit methods.

Based on research at a hospital in Surabaya, the occuring cost variance also cannot be separated from the existence of various influencing factors such as the coding system of diseases in the medical record is not in accordance with ICD-10 ( International Statistical Classification), delays in obtaining laboratory results, delays in service due to hospital staff office hours, length of hospital stay, and the presence of comorbid or even side effects from drugs that cause the actual cost of health services to swell. The existence of an operational audit also requires medical personnel in the hospital to carry out healthcare procedures in accordance with clinical pathways to patients, to create a match between standards and practices that should ideally be followed to manage patient diseases effectively and efficiently.

The outline obtained from the explanation points to the importance of conducting operational audits was to identify variance of healthcare service costs in this dynamic BPJS era. Hospitals get quality financial management and medical operations that are directed by the existence of operational audits that are carried out correctly and continuously. Recommendations from operational audits can be used as a source to determine hospital internal policies in providing best services to patients.


Author: Thinni Nurul Rochmah

The full article: Cost Variance of Health Services at PHC Hospital, Surabaya, Indonesia: Operational Audit . can be viewed at https://produccioncientificaluz.org/index.php/utopia/article/view/32079

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