Analisis Pending Klaim Rawat Inap Di Rumah Sakit Umum Daerah Waikabubak Tahun 2025

Sugiyanto, Vivi Sumarliyanti Ekowati (2025) Analisis Pending Klaim Rawat Inap Di Rumah Sakit Umum Daerah Waikabubak Tahun 2025. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Pending claims often occur due to incomplete or erroneous aspects of administration, medical records, or coding. At RSUD Waikabubak in 2024, 5.74% of inpatient claim files and 5% of outpatient claim files were pending. As a result, the hospital experienced cash flow disruptions, delays in payments, and a decline in service quality. This study aims to analyze the factors that affect inpatient pending claims at RSUD Waikabubak in 2025, based on the Robbins performance variables (motivation, opportunity, and ability).This is a qualitative study using data collection techniques such as documentation, observation, and interviews, while data validation was done through triangulation of techniques and sources. The study found that the motivation variable was a cause of pending claims due to the lack of evenly distributed rewards and punishments given to all staff. Based on the opportunity variable, there was a job description in the form of incomplete decrees, causing JKN-KIS staff to lack clarity, which resulted in pending claims. The facilities for JKN-KIS staff such as ICD-10/ICD-9 CM, computers, scanners, and printers were still limited, which slowed down the claim verification process. Furthermore, the SIMRS system had not been integrated with the e-claim system, and there were no SOPs regulating the claim verification process.As for the ability variable, several claims officers did not meet the required educational qualifications, had insufficient knowledge about BPJS claims and pending claims, and most had less than five years of experience, with minimal training or socialization. RSUD Waikabubak needs to implement a structured reward system, prepare clear job descriptions, complete the claim facilities, develop claim process SOPs, propose training for BPJS officers, and apply a rolling system based on educational qualifications to improve the effectiveness of claim management.

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