Insurance Claim Dispute Resolution at General Hospital in Pacitan
DOI:
https://doi.org/10.38035/dijemss.v7i5.6687Keywords:
Medical Services, Insurance Claim, and Dispute Resolution MechanismsAbstract
The discrepancy between the medical standards applied by health workers and the policy provisions of insurance companies often creates uncertainty for policyholders. This condition has led to the emergence of various legal disputes that have an impact on the fulfillment of patients' rights and the sustainability of health institution operations. This study aims to analyze the mechanism for handling and resolving health insurance claims disputes that occur at the institutional level. A descriptive qualitative approach is used to provide an in-depth overview of the settlement procedures, handling measures, and obstacles that arise at the Pacitan Regional General Hospital. The claim dispute resolution mechanism is implemented through cross-unit coordination that prioritizes a win-win solution approach through file reconciliation and synchronization of clinical actions with national practice guidelines. The main obstacles found include incompleteness of administrative documents, differences in diagnosis interpretation between hospitals and guarantors, and incompatibility of medical services with the set cost ceiling. The effectiveness of resolving this problem relies heavily on the use of quality and cost control instruments, such as the Clinical Pathway, to ensure that patients' medical rights are fulfilled according to scientific evidence. Transparent collaboration between professions in adjusting patient care to insurance policies has proven to be able to maintain the financial stability of hospital operations.
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