Analysis of Factors Causing BPJS Kesehatan Pending Claims Based on the INA-CBGs System at Hospital X

The National Health Insurance (JKN) program, managed by BPJS Kesehatan, implements the Indonesian Case-Based Groups (INA-CBGs) payment system for hospital service claims. The claims submission process still frequently encounters various obstacles, resulting in some claims being placed on hold and causing delays in payments to hospitals. This study aims to identify the factors causing BPJS Kesehatan claims to be pending under the INA-CBGs system at Hospital X. This study employs a qualitative method with a descriptive-analytical approach. Data were collected through in-depth interviews with medical records staff, coding staff, and claims staff, as well as through observation and a review of documentation regarding pending claims files. Data analysis was conducted using the Miles and Huberman model, which involves the stages of data reduction, data presentation, and drawing conclusions. The results of the study indicate that the most common causes of pending claims are readmission cases, discrepancies between supporting diagnostic documents and medical indications, and discrepancies in medical summaries. Inconsistencies in medical records result in the claim verification process requiring document corrections or additional documentation. The findings of this study are expected to serve as a basis for hospitals to evaluate and improve their management of BPJS Kesehatan claims so that the claims process can run more effectively and efficiently and support improvements in the quality of hospital service management.