Analisis Faktor Penyebab Pending Klaim BPJS Kesehatan Rawat Inap Di RSUD Cilacap

Putri, Imandini Anggimelya (2025) Analisis Faktor Penyebab Pending Klaim BPJS Kesehatan Rawat Inap Di RSUD Cilacap. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Pending inpatient claims for BPJS health inpatient at RSUD Cilacap from October 2023 to March 2024 reached 324 files, representing 3.67% of 8,818 submitted claims. These claims were categorized into medical, coding, and administrative groups. The pendency stemmed from internal verifiers' lack of thoroughness, coders' incomplete review of medical records, and groupers' failure to recheck claims. This qualitative study, utilizing Lawrence Green’s behavioral theory, aimed to analyze the predisposing, enabling, and reinforcing factors contributing to these pending claims. Data were collected through interviews, observations, documentation, USG, and brainstorming with nine subjects. The findings highlight several behavioral factors contributing to pending claims. These include inpatient coders occasionally struggling to select appropriate codes for claims, internal verifiers prioritizing time efficiency, and coders not adhering to coding procedures. Other issues identified were RME is not operating optimally due to declining server performance; a lack of training for internal verifiers and one coder; and insufficient monitoring and evaluation of claim submissions. Furthermore, problems such as changes in reward systems without sanctions, absent medical verification SPOs, incomplete coding SPOs, non-compliance with coding SPO implementation, irrelevant grouping SPOs, and inadequate socialization of coding and grouping SPOs were found. Recommendations for improvement include server replacement, claim submission training for coders, regular review and update of claim regulations, and monthly supervision and evaluation by the VI coordinator and IRM head. Evaluation results should be socialized to the DPJP and cashiers. Additionally, continuous monitoring and evaluation of all staff behavior are crucial.

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