Analisis Faktor Penyebab Klaim Pending Pasien BPJS Kesehatan Rawat Jalan di UPF Balai Kesehatan Mata Masyarakat Cikampek

Rosmayanti, Nur Fitri Rosmayanti (2024) Analisis Faktor Penyebab Klaim Pending Pasien BPJS Kesehatan Rawat Jalan di UPF Balai Kesehatan Mata Masyarakat Cikampek. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The implementation of the National Health Insurance (JKN) in Indonesia requires hospitals to submit claims to receive reimbursement for healthcare services. Social Health Insurance Administration Body (BPJS) claims are requests for payment of healthcare service fees by healthcare facilities to BPJS Kesehatan. The implementation of BPJS claims is not without challenges, one of which is pending claims cases. Based on preliminary study results, it is known that UPF BKMM Cikampek was still experiencing pending claims for BPJS outpatient services. In October-December 2023, out of 4,963 submitted files, 175 were found to have pending claims. This study analyzed the factors causing pending claims for BPJS Kesehatan Outpatient Service patients at UPF BKMM Cikampek based on Gibson's Performance Theory. This research are qualitative with data collection techniques using interviews, observations, documentation, and brainstorming with research informants consisting of the head of the medical record installation, patient verification and guarantor, claim PIC, outpatient coding grouping officers, claim entry officers, outpatient claim verification officers, claim document verification officers, and IT officers. The results of the study show several factors causing pending BPJS outpatient claims at UPF BKMM Cikampek on the individual variables were due to the mismatch of educational qualifications and the lack of training for claim officers evenly. Organizational variables are due to the evaluation of pending claim settlements that are not carried out routinely, the absence of special performance allowances for claim officers, and the absence of job descriptions and standard operating procedures for handling pending claims. The proposed efforts to resolve pending claim problems include rotating officers on the BPJS outpatient claim guarantee team, implementing routine meetings, and compiling job descriptions and standard operating procedures related to handling pending claims.

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