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All Journal Komitmen : Jurnal Ilmiah Manajemen
Dyah Putri Hermaningtyas
Universitas Muhammadiyah Surabaya
Economics, Econometrics & Finance Social Sciences

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ANALYSIS OF PENDING BPJS KESEHATAN CLAIMS BASED ON THE DONABEDIAN FRAMEWORK IN A PRIVATE HOSPITAL Dyah Putri Hermaningtyas; Setya Haksama; Annisa Nurida
KOMITMEN: Jurnal Ilmiah Manajemen Vol. 7 No. 2 (2026): KOMITMEN: Jurnal Ilmiah Manajemen
Publisher : FEBI UIN Sunan Gunung Djati Bandung

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15575/jim.v7i2.59124

Abstract

Pending claims withhold hospital revenue and disrupt liquidity, yet prior studies have generally been short in duration and examined only one or two contributing factors. This study analyzed BPJS Kesehatan claim submissions using the Donabedian framework over 47 months in a class C private hospital. A quantitative-dominant mixed-methods design was applied. Secondary data on all claims from January 2022 to November 2025 (total sampling, 124,716 claims) were extracted from the hospital management information system, V-Claim, and Casemix unit archives, analyzed descriptively and longitudinally, and triangulated with in-depth interviews with three key informants, which were analyzed thematically. A total of 13,539 claims (10.9%) were pending, withholding IDR 8,067,510,900 (12.4% of the total submitted claim value), and no rejected claims were recorded. The Process dimension accounted for 85.8% of pending causes, dominated by coding inaccuracy (77.4%), most of which involved episode-of-care merging rules for repeat visits; the Structure dimension accounted for 29.3%. The trend was non-linear: 24.7% (2022), 2.0% (2023), 11.3% (2024), and 9.1% (2025). Interviews identified discharge summary completeness and the absence of a dedicated internal verifier as strategic issues. Pending claims were concentrated in the Process dimension but were rooted in clinical documentation quality within the Structure dimension.
Co-Authors Annisa Nurida Setya Haksama