Analisis Faktor Penyebab PEnding Klaim BPJS Rawat Inap di Rumah Sakit Umum Daerah Tongas

Yulia, Rani Dwi (2026) Analisis Faktor Penyebab PEnding Klaim BPJS Rawat Inap di Rumah Sakit Umum Daerah Tongas. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Pending claims are conditions in which claim files submitted by the hospital to BPJS Kesehatan are returned due to deficiencies or discrepancies. The pending claims cases at RSUD Tongas during the period of January to June 2025 recorded a total of 2,104 patient visits, with a total of 296 pending cases or 14.07%. The purpose of this study was to analyze the factors causing BPJS inpatient pending claims at the hospital using the MOA method. Improvement efforts were carried out through discussion. This study used a qualitative research design with data collection techniques consisting of interviews, observations, and documentation. The results of this study showed that in the motivation variable, there was no recognition for staff performance, the punishment system had not been implemented evenly, and the leadership style supported work motivation. The opportunity variable indicated the availability of SOP for claim submission, completion of medical record documents, and diagnosis and procedure coding, but there was no SOP for pending claims. The ability variable showed that the educational qualifications of the staff had not met the minimum requirement of a Diploma III in Medical Records and Health Information, staff had no experience working as claim submission officers, some staff knowledge was not yet optimal, and there were staff who had never attended training. The conclusion of this study showed that the factors causing BPJS inpatient pending claims at RSUD Tongas consisted of the elements of Motivation, Opportunity, and Ability. The proposed improvement efforts included proposing the implementation of a reward and punishment system, developing an SOP for pending claims resolution, optimizing staff, providing mentoring and socialization, and proposing training

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