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All Journal Proceeding of International Conference Health, Science And Technology (ICOHETECH)
Tri Utami, Yeni
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Computer Science & IT Decision Sciences, Operations Research & Management Health Professions Industrial & Manufacturing Engineering Medicine & Pharmacology

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Implementation Of Poac Management (Planning, Organizing, Actuating And Controlling) In An Effort To Reduce The Number Of Pending Claims For Inpatient Bpjs In The Hospital Tri Utami, Yeni; Maryati, Warsi; Sri Rahayuningsih, Lilik Anggar
Proceeding of the International Conference Health, Science And Technology (ICOHETECH) 2024: Proceeding of the 5th International Conference Health, Science And Technology (ICOHETECH)
Publisher : LPPM Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/icohetech.v5i1.4207

Abstract

Problems with pending claims in hospitals are mostly caused by incomplete files and discrepancies in the accuracy of diagnosis codes. UNS Surakarta Hospital is known to find around 50-300 BPJS Inpatient claim files pending every month. This study aims to determine management in an effort to reduce the number of pending claims for inpatient BPJS patients in hospitals. This type of research is descriptive qualitative, with a cross sectional approach. The subjects of this research include claims coordinators, coders, internal verification officers and medical committee members (doctors). The research object is the claim file for Trimonths 4 of 2023. The instruments used are interview guidelines, observation guidelines, checklists. The research results showed that of the 2289 claim files submitted, 168 files (7.34%) were pending, which were divided into 3 factor classifications, namely Medical Aspects 62 files (36.90%), Administrative Aspects 57 files (33.93%) and Coding Aspect 49 files (29.17%). The process of handling pending claims based on planning, organizing, actuating and controlling aspects is still not running optimally. This is caused by the lack of clear division of job descriptions and the absence of SOPs related to handling pending claims which are only manifested in official notes, in general evaluations are still carried out based on cases but not based on users which causes there to be no rewards and punishments for officers who do not comply. It would be better for hospitals to prepare SOPs for filling out BPJS claim requirements files, and make clear job desk divisions, especially the BPJS coding section, and implement Inpatient RME immediately.
Implementation Of Poac Management (Planning, Organizing, Actuating And Controlling) In An Effort To Reduce The Number Of Pending Claims For Inpatient Bpjs In The Hospital Tri Utami, Yeni; Maryati, Warsi; Sri Rahayuningsih, Lilik Anggar
Proceeding of the International Conference Health, Science And Technology (ICOHETECH) 2024: Proceeding of the 5th International Conference Health, Science And Technology (ICOHETECH)
Publisher : LPPM Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/icohetech.v5i1.4207

Abstract

Problems with pending claims in hospitals are mostly caused by incomplete files and discrepancies in the accuracy of diagnosis codes. UNS Surakarta Hospital is known to find around 50-300 BPJS Inpatient claim files pending every month. This study aims to determine management in an effort to reduce the number of pending claims for inpatient BPJS patients in hospitals. This type of research is descriptive qualitative, with a cross sectional approach. The subjects of this research include claims coordinators, coders, internal verification officers and medical committee members (doctors). The research object is the claim file for Trimonths 4 of 2023. The instruments used are interview guidelines, observation guidelines, checklists. The research results showed that of the 2289 claim files submitted, 168 files (7.34%) were pending, which were divided into 3 factor classifications, namely Medical Aspects 62 files (36.90%), Administrative Aspects 57 files (33.93%) and Coding Aspect 49 files (29.17%). The process of handling pending claims based on planning, organizing, actuating and controlling aspects is still not running optimally. This is caused by the lack of clear division of job descriptions and the absence of SOPs related to handling pending claims which are only manifested in official notes, in general evaluations are still carried out based on cases but not based on users which causes there to be no rewards and punishments for officers who do not comply. It would be better for hospitals to prepare SOPs for filling out BPJS claim requirements files, and make clear job desk divisions, especially the BPJS coding section, and implement Inpatient RME immediately.
FACTORS CAUSING PENDING BPJS HEALTH CLAIMS IN HOSPITALS: A QUALITATIVE STUDY Tri Utami, Yeni; Maryati, Warsi; Eka Wardaya, Aloysios
Proceeding of the International Conference Health, Science And Technology (ICOHETECH) 2026: Proceeding of the 7th International Conference Health, Science And Technology (ICOHETECH)
Publisher : LPPM Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/kt4svz15

Abstract

Pending BPJS Kesehatan claims remain a problem in hospital financing management. Based on BPJS Kesehatan data in 2024, approximately 3 percent of healthcare claim costs, or approximately IDR 5 trillion, were recorded as pending claims, and this trend has reportedly increased significantly in several hospitals, including Indriati Solobaru Hospital. This study aims to identify the factors causing pending claims. The research method used descriptive qualitative with a cross-sectional approach. The object of the study was inpatient claims data at Indriati Solobaru Hospital in 2025. The research subjects were 11 claims officers selected purposively. Qualitative data were collected through focus group discussions and interviews. The results of the 2025 claims data study showed 10,820 inpatient claims, with 3,202 claims (29.59%) pending. Coding factors were the largest category (60.27%), followed by medical aspects (26.20%) and administration (13.52%). Analysis of the results of claims officer interviews revealed five interrelated factors, namely incomplete and inconsistent clinical documentation, coding complexity and clinical suitability, regulatory dynamics, governance and cross-professional coordination, and limited integration of RME-SIMRS-INA-CBGs. These results indicate that pending claims are a multidimensional problem that requires hospitals to address them by simultaneously improving clinical documentation, coding, regulatory adaptation, coordination, and system integration as an effort to increase claim success.
Co-Authors Eka Wardaya, Aloysios Lilik Anggar Sri Rahayuningsih Maryati, Warsi