ANALISIS PENERIMAAN KLAIM BPJS KESEHATAN DI RS HERMINA MEDAN TAHUN 2025: ANALYSIS OF BPJS HEALTH CLAIM ACCEPTANCE AT HERMINA MEDAN HOSPITAL IN 2025 - Rafika Aulia Nisa; Arifah Devi Fitriani; Asriwati (Fakultas Kedokteran Universitas Islam Sumatera Utara, 2026)
The issue of pending BPJS Kesehatan claims is a crucial issue that directly impacts the financial stability and service efficiency of hospitals. Delayed claims not only hamper the institution's cash flow, but also disrupt operational continuity and medical staff satisfaction. This study aims to analyze the acceptance of BPJS Kesehatan claims at Hermina Hospital in Medan in 2025 and assess the effectiveness of policy implementation and standard operating procedures (SOPs) in the claims process. This study uses a descriptive qualitative approach with in-depth interviews and is supplemented by a documentation study of SOP documents and hospital claim reports. The data were analyzed using thematic coding techniques (open coding, axial coding, and selective coding). The results showed that the most frequently emerging themes were incomplete medical records due to delayed uploading of supporting examination results to the system; inaccurate diagnosis codes; and coders' limited understanding of diagnosis determination. The documentation study showed that the implementation of SOPs was not yet optimal because internal audits were still conducted retrospectively. The conclusion that can be drawn is that the problem of pending BPJS claims is multidimensional and systemic (administrative, technical, and managerial aspects). Efforts to improve claim effectiveness through ongoing training for coders and verifiers, optimization of internal audits, and strengthening the digitization of SIMRS-based claim processes need to be carried out. AbstrakPermasalahan pending klaim BPJS Kesehatan merupakan isu krusial yang berdampak langsung terhadap stabilitas keuangan dan efisiensi pelayanan rumah sakit. Proses klaim yang tertunda tidak hanya menghambat arus kas institusi, tetapi juga mengganggu kesinambungan operasional dan kepuasan tenaga medis. Penelitian ini bertujuan untuk menganalisis penerimaan klaim BPJS Kesehatan di Rumah Sakit Hermina Medan tahun 2025 serta menilai efektivitas pelaksanaan kebijakan dan prosedur operasional standar (SPO) dalam proses klaim. Penelitian ini menggunakan pendekatan kualitatif deskriptif dengan metode wawancara mendalam serta dilengkapi dengan studi dokumentasi terhadap dokumen SOP dan laporan klaim rumah sakit. Data dianalisis menggunakan teknik tematik (open coding, axial coding, dan selective) coding. Hasil penelitian menunjukkan bahwa tema yang paling sering muncul adalah ketidaklengkapan dokumen rekam medis akibat hasil pemeriksaan penunjang yang terlambat diunggah ke sistem; ketidaktepatan kode diagnosis; dan keterbatasan pemahaman coder terhadap penentuan diagnosis. Studi dokumentasi menunjukkan bahwa implementasi SPO belum optimal karena audit internal masih dilakukan secara retrospektif. Kesimpulan yang dapat diambil adalah permasalahan pending klaim BPJS bersifat multidimensional dan sistemik (aspek administrasi, teknis, dan manajerial). Upaya peningkatan efektivitas klaim melalui pelatihan berkelanjutan bagi koder dan verifikator, optimalisasi audit internal, serta penguatan digitalisasi proses klaim berbasis SIMRS perlu dilakukan.