Analysis of Factors Causing Pending Claims for Inpatient JKN Patients Using the Fishbone Diagram Method Approach at Hospital X

Sulastri Rahayu; Ratna Indrawati

doi:10.55927/fjst.v4i6.130

Authors

Sulastri Rahayu Klinik Pratama Keysa
Ratna Indrawati Klinik Pratama Keysa

DOI:

https://doi.org/10.55927/fjst.v4i6.130

Keywords:

BPJS, Pending Claims, Fishbone Diagram

Abstract

Since the implementation of the National Health Insurance (JKN) program as of January 1, 2014, the profile of hospital patients has undergone many shifts, which are currently dominated by BPJS Kesehatan guarantee patients, this means that the largest health financing comes from BPJS Kesehatan claim payments. Claim files that do not meet the requirements will be returned to the hospital, this will have an impact on reduced claim payments. Preliminary study at the hospital. X found that the number of pending claims for hospitalization for the month of January to March 2025 reached an average of 18.1% of files. This study aims to analyze the factors that cause the pending claims of hospitalization of JKN patients in hospitals. X with the fishbone diagram method approach. This research is qualitative, data collection using secondary data, observation, interviews, and document review. The results of this study show the causes of pending claims from the man factor: quality and quantity of coding, material factors: incomplete files (machine): lack of scanner equipment and process factors (method): SOP and regulations related to inadequate coding. The root causes of the problem include a lack of number, education and training of coder officers, lack of claim file filters, lack of number and quality of scanners and incomplete and not updating SOPs and regulations related to coding activities.

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