EVALUASI VERIFIKASI INTERNAL KLAIM PENDING KASUS RAWAT INAP BPJS KESEHATAN DI RSUD dr. R SOETRASNO REMBANG (Studi Kasus Klaim Pending Rawat Inap BPJS Kesehatan Akibat Koding Rekam Medis)

Swastika Juni Suryandari, Dr. Dra. Diah Ayu Puspandari, Apt.,MBA.,M.Kes.,A.A.K

2026 | Tesis | MAGISTER KEBIJAKAN DAN MANAJEMEN KESEHATAN

ABSTRAK

Latar Belakang : Implementasi program Jaminan Kesehatan Nasional (JKN) menuntut rumah sakit untuk melakukan pengajuan klaim secara tepat dan akurat guna memastikan kelancaran pembiayaan layanan. Adanya klaim pending, terutama akibat ketidaktepatan kodefikasi rekam medis. Di RSUD dr. R. Soetrasno Rembang merupakan penyebab utama. Klaim pending Januari–Juni 2024 sebanyak 601 kasus (Rp. 3,91 miliar), di mana 40,5% disebabkan oleh permasalahan koding. Kondisi ini berpotensi mengganggu arus kas rumah sakit dan kelancaran layanan kesehatan.

Tujuan : Penelitian ini untuk mengevaluasi proses verifikasi internal klaim BPJS Kesehatan, mengidentifikasi faktor-faktor penyebab klaim pending akibat ketidaktepatan koding rekam medis, serta merumuskan rekomendasi strategis untuk perbaikan.

Metode : Jenis penelitian ini adalah kualitatif dengan desain studi kasus tunggal holistik. Data primer diperoleh melalui wawancara mendalam terhadap 10 informan kunci. Data sekunder diambil dari berita acara hasil verifikasi BPJS Kesehatan dan laporan klaim pending. Analisis data dilakukan melalui transkripsi, kategorisasi tematik, triangulasi data, dan pengembangan eksplanasi.

Hasil : Proses verivikasi internal berjalan belum optimal sehingga alur tidak berjalan linear maju. Faktor penyebab klaim pending akibat koding rekam medis meliputi: (1) ketidak lengkapan dokumen, (2) keterbatasan pengetahuan dari coder, (3) kurangnya koordinasi internal dan eksternal terhadap regulasi BPJS Kesehatan, (4) keterbatasan prasarana teknologi informasi dan (5) human eror. Penelitian ini menghasilkan rekomendasi strategis yang dikelompokkan menjadi jangka pendek (sosialisasi, bedah kasus pending, pertemuan rutin), jangka menengah (revisi alur verifikasi, pelatihan coder, sistem kluster), dan jangka panjang (advokasi kebijakan dan pengembangan aplikasi proses verifikasi terintegrasi).

Kesimpulan : Identifikasi faktor penyebab klaim pending akibat koding rekam medis di RSUD dr. R. Soetrasno Rembang serta penerapan rekomendasi strategis berbasis prinsip Total Quality Management (TQM) dan pendekatan SMART diharapkan dapat mengurangi risiko klaim pending di masa mendatang.

Kata Kunci : verifikasi internal, klaim pending BPJS Kesehatan, koding rekam medis, studi kasus holistik.

ABSTRACT

Background : The implementation of the National Health Insurance (JKN) program requires hospitals to submit claims accurately and appropriately to ensure smooth financing of healthcare services. Pending claims, particularly those caused by inaccuracies in medical record coding, have become a major issue at RSUD dr. R. Soetrasno Rembang. Between January and June 2024, 601 pending claims (IDR 3.91 billion), of which 40.5% were due to coding problems. This condition has the potential to disrupt hospital cash flow and hinder the continuity of healthcare services.

Objective : This study aims to evaluate the internal verification process of BPJS Health claims, identify the factors contributing to pending claims caused by medical record coding, and formulate strategic recommendations for improving the coding process..

Methods : This research employs a qualitative approach with a holistic single-case study design. Primary data were collected through in-depth interviews with 10 key informants. Secondary data were obtained from official records of BPJS Health verification results and reports on pending claims. Data analysis was conducted through transcription, thematic categorization, data triangulation, and explanation building.

Results : The factors contributing to pending claims due to medical record coding include: (1) incomplete documentation during the assembling stage, (2) inaccurate coding resulting from insufficient understanding of the latest regulations by coders, (3) suboptimal internal and external coordination, (4) information technology constraints, and (5) human error in data entry. This study proposes strategic recommendations categorized into short-term (socialization, case reviews of pending claims, regular meetings), medium-term (revision of verification workflows, coder training, cluster system implementation), and long-term (policy advocacy and development of an integrated claims application).

Conclusion : The identification of factors causing pending claims due to medical record coding at RSUD dr. R. Soetrasno Rembang, along with the implementation of strategic recommendations based on Total Quality Management principles and the SMART approach, is expected to reduce the risk of pending claims in the future.

Keywords : internal verification, pending claims, BPJS Health, medical record coding, holistic case study.

Kata Kunci : verifikasi internal, klaim pending BPJS Kesehatan, koding rekam medis, studi kasus holistik.