ANALISIS FAKTOR PENYEBAB PENDING CLAIM BPJS DI RSU PKU MUHAMMADIYAH DELANGGU

Yuniarida Dwijayanti, Andreasta Meliala, Dr., dr., DPH., Mkes, MAS.

2025 | Tesis | MAGISTER KEBIJAKAN DAN MANAJEMEN KESEHATAN

ANALISIS FAKTOR PENYEBAB PENDING CLAIM BPJS DI RSU PKU 

MUHAMMADIYAH DELANGGU

Yuniarida Dwijayanti1, Andreasta Meliala2 

1 Mahasiswa Program Pasca Sarjana, Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan, Universitas Gadjah Mada

2 Departemen Keperawatan Dasar dan Emergensi, Fakultas Kedokteran, Kesehatan Masyarakat dan Keperawatan, Universitas Gadjah Mada

ABSTRAK

Latar Belakang: Pemerintah Indonesia menjalankan program Jaminan Kesehatan Nasional (JKN) yang diselenggarakan oleh Badan Penyelenggara Jaminan Sosial (BPJS) menggunakan sistem pembiayaan prospektif berbasis tarif paket atau Casemix sehingga diperlukan pengelolaan khusus untuk pelaksanaan program JKN di rumah sakit agar tidak terjadi klaim pending sesuai dengan persyaratan yang ditetapkan BPJS Kesehatan. Terjadi peningkatan pending claim BPJS dapat disebabkan pengiriman berkas yang masih kurang lengkap, petugas salah memasukkan data, jaringan internet sering terkendala, petugas IT belum berfungsi optimal. RSU PKU Muhammadiyah Delanggu sedang mengalami perkembangan yang pesat namun faktanya klaim yang pending masih tinggi setiap bulannya. Pending claim di Rumah Sakit ini terjadi pada rawat jalan dan rawat inap, namun nominal angka pending claim pada rawat inap lebih besar dibandingkan pending claim rawat jalan.

Tujuan: Menganalisis faktor penyebab pending claim BPJS di RSU PKU Muhammadiyah Delanggu

Metode: Desain penelitian Emik dengan pendekatan kualitatif. Wawancara, observasi dan dokumentasi sebagai data penunjang. Subjek penelitian ini adalah pegawai yang berhubungan dengan aktifitas komunikasi dan input data rekam medis elektronik meliputi perawat/bidan, dokter, petugas administrasi/petugas pendaftran rawat inap, structural manajemen RS, dan petugas klaim BPJS rawat inap. Hasil kualitatif ditampilkan dalam join display.

Hasil: Terdapat 7 tema utama penyebab pending claim, yaitu: (1) kesalahan koding diagnosis dan tindakan; (2) ketidaklengkapan berkas administrasi; (3) faktor medis dan keterlambatan hasil penunjang; (4) human error dan ketidaktelitian petugas; (5) gangguan sistem informasi; (6) perbedaan pemahaman regulasi antara rumah sakit dan BPJS; dan (7) keterbatasan SDM serta minimnya pelatihan. Selain itu, belum optimalnya upaya pengawasan dan verifikasi internal juga turut menjadi kendala dalam mencegah klaim tertunda.

Kesimpulan: Pending claim BPJS paling dominan disebabkan faktor sumber daya manusia, human error, dan sistem teknologi. Diperlukan upaya perbaikan melalui pembentukan tim verifikator, integrasi sistem pemeriksaan penunjang, peningkatan pelatihan, serta harmonisasi regulasi dengan BPJS.

Kata Kunci: Faktor, penyebab pending claim BPJS 

IYAH DELANGGU

ANALYSIS OF FACTORS CAUSING PENDING BPJS CLAIMS AT RSU PKU MUHAMMADIYAH DELANGGU

 

Yuniarida Dwijayanti1, Andreasta Meliala2 

1 Postgraduate Student, Faculty of Medicine, Public Health and Nursing, University of Gadjah Mada

2 Department of Basic and Emergency Nursing, Faculty of Medicine, Public Health and Nursing, University of Gadjah Mada

ABSTRACT

Background: The Indonesian government runs the National Health Insurance (JKN) program organized by the Social Security Organizing Agency (BPJS) using a prospective financing system based on package rates or Casemix so that special management is needed for the implementation of the JKN program in hospitals so that there are no pending claims in accordance with the requirements set by BPJS Health. An increase in pending BPJS claims can be caused by sending files that are still incomplete, officers enter data incorrectly, internet networks are often constrained, IT officers have not functioned optimally. RSU PKU Muhammadiyah Delanggu is experiencing rapid development but the fact is that pending claims are still high every month by the BPJS health verifier. Pending claims in this hospital occur in outpatient and inpatient care, but the nominal number of pending claims in inpatient care is greater than outpatient pending claims.

Aims: To analyze the factors causing pending BPJS claims at PKU Muhammadiyah Delanggu Hospital.

Methods: Research design with a qualitative approach. Interview, observation and documentation as supporting data. The subjects of this study were employees related to communication activities and electronic medical record data input including nurses/midwives, doctors, administrative officers/inpatient registration officers, structural hospital management, and inpatient BPJS claim officers. Qualitative results are displayed in join display.

Result: There were 7 main themes causing pending claims, namely: (1) diagnosis and action coding errors; (2) incomplete administrative files; (3) medical factors and delays in supporting results; (4) human error and officer inaccuracy; (5) information system disruptions; (6) differences in understanding of regulations between hospitals and BPJS; and (7) limited human resources and lack of training. In addition, suboptimal internal supervision and verification efforts are also an obstacle in preventing delayed claims.

Conclussion: Pending BPJS claims are mostly caused by human resources, human error, and technology systems. Improvement efforts are needed through the formation of a verifier team, integration of supporting examination systems, increased training, and harmonization of regulations with BPJS.

Keyword: Factors, causes of pending BPJS claims 

Kata Kunci : Faktor, penyebab pending claim BPJS