Analisis Faktor Penyebab Pending Klaim BPJS Kesehatan pada Kasus Fragmentasi di Unit Rawat Jalan Rumah Sakit Citra Husada Jember

Isnaeni, Wa Ode (2026) Analisis Faktor Penyebab Pending Klaim BPJS Kesehatan pada Kasus Fragmentasi di Unit Rawat Jalan Rumah Sakit Citra Husada Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Pending BPJS Kesehatan claims in fragmentation cases are one of the problems that hinder the claim disbursement process in hospitals. Based on a preliminary study at Citra Husada Hospital Jember, in December 2024 there were 882 pending claims due to fragmentation. This problem is suspected to be caused by BPJS controllers perceiving that the calculation of the seven-day period starts from the patient's scheduled arrival day. However, when submitting a claim, the claim is rejected with confirmation that the patient's control period is ≤7 days (fragmentation), in addition to the lack of standard operating procedures that specifically regulate the management of fragmentation handling according to BPJS Kesehatan provisions, resulting in pending claims. Therefore, this study aims to analyze the factors causing pending BPJS Kesehatan claims in fragmentation cases based on Gibson's performance theory. The study used a qualitative method with data collection techniques in the form of interviews, observation, documentation, and written tests on 5 BPJS Kesehatan Control Team officers. The results showed that the written test confirmed that there were still differences in officers' understanding of fragmentation provisions. In individual variables, factors causing pending claims include lack of ability, skills, and experience of officers. In organizational variables, factors causing pending claims include incomplete job descriptions and the lack of fragmentation Standard Operating Procedures. In psychological variables, factors causing pending claims include differences in officer perceptions regarding patient check-up schedules, exception conditions for fragmentation, and suboptimal external socialization. The conclusion of this study is that the causes of pending claims are influenced by individual, organizational, and psychological factors, so that it is necessary to align officer perceptions, develop fragmentation SOPs, and conduct regular internal socialization to minimize the occurrence of pending claims. Keywords : BPJS Kesehatan, claims, pending claims, fragmentation, performance theory

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