Lidia Lorenza Lorenza; Laili Ilmi; Umi Khoirun Nisak

doi:10.52943/jipiki.v11i2.2282

Authors

Lidia Lorenza Lorenza Universitas Muhammadiyah Sidoarjo
Laili Ilmi Universitas Muhammadiyah Sidoarjo
Umi Khoirun Nisak Universitas Muhammadiyah Sidoarjo

DOI:

https://doi.org/10.52943/jipiki.v11i2.2282

Keywords:

BPJS Claims, Clinical Coding Medical Records, Pending Claims Inpatient

Abstract

Pending claims remain a common issue in the BPJS Health reimbursement process and may delay hospital claim payments. This study aimed to analyze the completeness of claim documents, the accuracy of diagnosis coding, and the factors contributing to pending inpatient BPJS claims at RSUD Sidoarjo Barat. A descriptive quantitative study with a prospective approach was conducted using 98 inpatient claim files selected through purposive sampling. Data were collected through observation using a checklist and analyzed descriptively. The results showed that all claim files were administratively complete (100%). Diagnosis coding was accurate in 85% of the files, while 15% were still inaccurate. Claim verification indicated that 86% of claims were eligible for payment and 14% remained pending. Medical factors were identified as the main cause of pending claims, followed by administrative and supporting factors. The findings indicate that complete documents alone cannot prevent pending claims if diagnosis coding is still inaccurate. Therefore, improving coding accuracy and claim verification is necessary to reduce pending BPJS claims.

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References

U. K. Nisak, L. R. Ilmi, N. I. Natasya, C. A. Kinanthi, and C. Cholifah, “Transforming Medical Records Into Actionable Insights Through Data Visualization Dashboards,” Journal of Social Community Services (JSCS), Vol. 2, No. 1, pp. 34–41, Dec. 2024.

K. E. M. Msiska, A. Kumitawa, and B. Kumwenda, “Factors Affecting the Utilisation of Electronic Medical Records System in Malawian Central Hospitals,” Malawi Medical Journal, Vol. 29, No. 3, 2017.

BPJS Kesehatan, “Petunjuk Teknis Penjaminan Pelayanan Kesehatan dengan Asuransi Kesehatan Tambahan dalam Program Jaminan Kesehatan,” 2020.

N. K. Ningtyas, S. Sugiarsi, and A. S. Wariyanti, “Analisis Ketepatan Kode Diagnosis Utama Kasus Persalinan Sebelum dan Sesudah Verifikasi pada Pasien BPJS di RSUP Dr. Soeradji Tirtonegoro Klaten,” Vol. 4, No. 1, pp. 1–11, 2019.

P. Laili Rahmatul Ilmi and Lau Lee Yen Rachmani, “Tinjauan Kelengkapan Kode Kasus Kecelakaan dan …,” Proceeding Seminar Nasional DPP PORMIKI, 2020.

L. R. Ilmi and I. R. Sayekti, “The Design of Discharge Summary for Patients of Continuous Care,” Vol. 514, No. ICOSHIP 2020, pp. 210–215, 2021.

L. R. Ilmi and Z. Purbobinuko, “Penentu Penyebab Kematian di RSUD Panembahan Senopati Bantul: Miscoding Berdampak pada Laporan Statistik Kematian,” Jurnal Manajemen Informasi Kesehatan Indonesia, Vol. 8, No. 1, p. 86, 2020.

O. Oktamianiza, R. Rahmadhani, Y. Yulia, V. Ilahi, K. A. Putri, and F. S. Juwita, “Penyebab Pending Klaim Berdasarkan Aspek Diagnosis dan Ketepatan Kode Diagnosis,” J-REMI: Jurnal Rekam Medik dan Informasi Kesehatan, Vol. 5, No. 4, pp. 282–287, Jul. 2024.

R. Tuzzahra, A. O. Hakim, D. Romodon, and G. Gunawan, “Penyebab Pengembalian Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Ditinjau dari Syarat-Syarat Pengajuan Klaim di RSUD Majenang,” J-REMI: Jurnal Rekam Medik dan Informasi Kesehatan, Vol. 6, No. 1, pp. 29–39, Dec. 2024.

B. Wahyudi and K. Mulyani, “Analisis Penyebab Pending Klaim Pasien BPJS Rawat Inap dalam Rangka Mengoptimalkan Pendapatan di RSUD Banten,” Action Research Literate, Vol. 8, No. 12, 2024.

E. S. Maulida and A. Djunawan, “Analisis Penyebab Pending Claim Berkas BPJS Kesehatan Pelayanan Rawat Inap Rumah Sakit Universitas Airlangga,” Media Kesehatan Masyarakat Indonesia, Vol. 21, No. 6, pp. 374–379, Dec. 2022.

H. Meissner, J. Creswell, A. C. Klassen, V. Plano, and K. C. Smith, “Best Practices for Mixed Methods Research in the Health Sciences.”

S. L. Stick and N. Lincoln, “Using Mixed-Methods Sequential Explanatory Design: From Theory to Practice,” Vol. 18, No. 1, pp. 3–20, 2006.

G. Alfiansyah, P. N. Jember, P. N. Jember, M. W. Santi, and P. N. Jember, “Optimalisasi Manajemen Penanganan Klaim Pending Pasien BPJS Rawat Inap di Rumah Sakit Citra Husada Jember,” 2019.

M. Puspitaningsih, C. Suryawati, and S. P. Arso, “Evaluasi Administrasi Klaim BPJS Kesehatan dalam Menurunkan Klaim,” Jurnal Ilmiah Indonesia, Vol. 7, No. 8.5.2017, pp. 2003–2005, 2022.

L. W. Noviatri, “Analisis Faktor Penyebab Keterlambatan Penyerahan Klaim BPJS di RS Panti Nugroho,” Vol. 1, No. 1, pp. 22–26, 2016.

V. Alonso et al., “Health Records as the Basis of Clinical Coding: Is the Quality Adequate? A Qualitative Study of Medical Coders’ Perceptions,” Health Information Management Journal, Vol. 49, No. 1, pp. 28–37, 2020.

J. Shepheard, “Clinical Coding and the Quality and Integrity of Health Data,” Vol. 49, No. 1, pp. 3–4, 2020.

C. Opitasari and A. Nurwahyuni, “The Completeness and Accuracy of Clinical Coding for Diagnosis and Medical Procedure on the INA-CBGs Claim Amounts at a Hospital in South Jakarta,” Vol. 9, No. 1, pp. 14–18, 2018.

D. W. Bratzler et al., “An Administrative Claims Model for Profiling Hospital 30-Day Mortality Rates for Pneumonia Patients,” Vol. 6, No. 4, 2011.

C. Doktorchik, M. Lu, H. Quan, C. Ringham, and C. Eastwood, “A Qualitative Evaluation of Clinically Coded Data Quality from Health Information Manager Perspectives,” Health Information Management Journal, Vol. 49, No. 1, pp. 19–27, 2020.

B. Garret and Gangopadhyaya, “How the COVID-19 Recession Could Affect Health Insurance Coverage,” 2020.