FACTORS CAUSING PENDING BPJS HEALTH CLAIMS IN HOSPITALS: A QUALITATIVE STUDY
DOI:
https://doi.org/10.47701/kt4svz15Keywords:
Pending claims, BPJS Health, clinical coding, medical records, qualitative studiesAbstract
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.
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