Health Insurance Implementation at Hospital

 

Syllabus for course at advanced level

 

Course Name

Health insurance implementation at hospital

 

Course code : KUKM 2111301 (Elective)

Department: : Department of Health Policy and Management

Main field : Health Financing

Term : Semester 1

Time commitment : 120 hours

 

Prerequisites and special admittance requirements

Admitted to the master’s program in health policy and management.

 

Course content

The development of the National Health Insurance (JKN) system has brought major changes in the health service delivery system in hospitals. Hospitals are required to provide quality and efficient health services. Various demands for change must be made by hospitals in order to sustain and adapt to the new system, especially the prospective payment model (INA-CBGs).

This course is present, motivated by the needs of students who must understand the processes, expectations and problems in hospitals in running health insurance. Not only related to administration but also quality improvement, such as clinical pathways, audits, and case managers.

This course aims to provide an understanding of the relationship between hospitals and health insurance institutions and the process of service delivery related to service funding from third parties, coding systems in INA-CBGs, claims administration and solutions. The demand for quality services requires clinical pathways and medical audits as one of the mechanisms for quality control and cost control by service actors in hospitals. Not limited to these objectives, this course also discusses the latest issues, including cost sharing, JKN standard inpatient classes, etc. in the implementation of JKN in hospitals.

 

Learning objectives

After completing the course the student should be able to:

  1. Identify the implementation of health insurance in hospitals
  2. Identify the relationship between hospitals and health insurance
  3. Describe case management and the role of case managers in health insurance services
  4. Discuss the opportunities and challenges of hospitals working with health insurance 
  5. Apply the coding system in INA-CBGs 
  6. Demonstrate INA-CBGs software 
  7. Analyze the role of hospital installations in INA-CBGs payment
  8. Propose claim management in hospitals 
  9. Adjust cultural changes in INA-CBGs payment
  10. Analyze the credentialing process 
  11. Create service quality indicators in health insurance (AHQR) 
  12. Develop clinical audit 
  13. Evaluate clinical pathway

 

Topics

  1. Introduction to Health Insurance Implementation in Hospitals
  2. Hospital Relationship with Health Insurance
  3. Coding System in INA-CBGs
  4. Introduction to INA-CBGs Software
  5. Installation Role in INA-CBGs Payment
  6. Claims Management in Hospitals
  7. Culture Change in INA-CBGs Payment
  8. Credentialing
  9. Service Quality Indicators in Health Insurance (AHQR)
  10. Clinical Audit
  11. Clinical Pathway
  12. Case Management and Case Manager in Insurance Services 
  13. Discussion:  Opportunities and Threats of Hospitals in collaboration with health insurance

 

Education

The teaching consists of:

  • Lectures
  • Self-study through eLearning
  • Quizzes/assignments/discussion forum in eLearning: Case-based learning
  • Online synchronous discussion

The teaching is delivered through a combination of 60% in-person classes and 40% online classes.

 

Forms of examination

The course is examined through:

  • Written assignments, 20%
  • Skill-based assessment, 20%
  • Final examination, 60%

 

Required reading

  • Bhisma Murti. 2000. Dasar-dasar Asuransi Kesehatan. Kanisius
  • Kongsvedt, P.R, 2013, Essentials of Managed Health Care, 6th ed. Jones and Barlett Learning.
  • Kongsvedt, P.R, 2016, Health Insurance and Managed Care: What they are and how they work, 4th ed. Jones and Barlett Learning.
  • RI, 2012, Peta Jalan Jaminan Kesehatan Nasional 2012 – 2019, Jakarta.
  • Thabrany, H, 2014, Jaminan Kesehatan Nasional, Radjawali Press, Jakarta