Analysis of Factors Causing Pending BPJS Health Claims in Cerebral Infraction in Inpatiens

Abstract

Background: Pending BPJS Health claims for inpatients diagnosed with cerebral infarction can cause delays in fund disbursement and impact hospital cash flow. Objective: This study aims to analyze the factors causing pending BPJS Health claims for inpatients diagnosed with cerebral infarction using the fishbone diagram method at Hospital X in 2025. Methods: This study employed a qualitative descriptive method with a retrospective approach. Data collection was conducted through observation, interviews, and a review of data related to pending BPJS Health claims for inpatients diagnosed with cerebral infarction in 2025. Results: The results showed that there were 422 cases of pending claims, consisting of 19 cases (2.73%) related to administrative aspects, 421 cases (60.40%) related to coding aspects, and 257 cases (36.87%) related to medical aspects. The most dominant issues occurred in the coding aspect, particularly regarding the confirmation of new cerebral infarction or sequelae codes, as well as the removal of hemiplegia codes, which are clinical manifestations of cerebral infarction. Fishbone analysis indicates that the causes of pending claims stem from man, machine, method, and material factors, with the dominant factor being differences in perception between coders and BPJS Kesehatan verifiers. Conclusion: Therefore, improved coordination, evaluation, and alignment of perceptions between hospitals and BPJS Kesehatan are necessary to reduce the occurrence of pending claims.