Analysis of Factors Causing Pending BPJS Kesehatan Claims in Outpatients at Al Ihsan Hospital, West Java Province

Erix Gunawan; Helmy Dwi Muchtar Angraini

Erix Gunawan Politeknik Piksi Ganesha
Helmy Dwi Muchtar Angraini Politeknik Piksi Ganesha

Keywords: pending, claim; BPJS; Outpatient

Abstract

This study discusses the causes of pending BPJS Kesehatan claims in outpatients at Al Ihsan Hospital, West Java Province using a quantitative descriptive approach and observational methods. This study aims to analyze the factors causing pending claims based on the results of BPJS Kesehatan verification which focuses on three main aspects, namely codification of rules, service standards, and administrative completeness. The research population is 4,862 cases of pending claims in November 2024 with a sample of 98 cases determined by the Slovin formula (10% margin of error) and random sampling techniques. Data collection was carried out through an observation checklist table and analyzed univariately. The results showed that the highest cause came from the codification of rules (35.71%), followed by service standards (32.65%) and administration (31.63%). It is recommended that hospitals continue to conduct training for medical personnel by Clinical Pathway and BPJS service standards, increase the accuracy of administrative personnel, and provide additional supervision and training for coders. Regular reviews of the claims process are also needed to identify and fix the problem faster.

Author Biography

Erix Gunawan, Politeknik Piksi Ganesha

This study discusses the causes of pending BPJS Kesehatan claims in outpatients at Al Ihsan Hospital, West Java Province using a quantitative descriptive approach and observational methods. This study aims to analyze the factors causing pending claims based on the results of BPJS Kesehatan verification which focuses on three main aspects, namely codification of rules, service standards, and administrative completeness. The research population is 4,862 cases of pending claims in November 2024 with a sample of 98 cases determined by the Slovin formula (10% margin of error) and random sampling techniques. Data collection was carried out through an observation checklist table and analyzed univariately. The results showed that the highest cause came from the codification of rules (35.71%), followed by service standards (32.65%) and administration (31.63%). It is recommended that hospitals continue to conduct training for medical personnel by Clinical Pathway and BPJS service standards, increase the accuracy of administrative personnel, and provide additional supervision and training for coders. Regular reviews of the claims process are also needed to identify and fix the problem faster.