MANAGEMENT OF PENDING BPJS INPATIENT CLAIMS HANDLING

Abstract

Background: Pending claims refer to claim returns for which no agreement has been reached between BPJS Kesehatan and the Advanced Referral Health Facility. At Mawar General Hospital Banjarbaru, in 2023, claim returns by BPJS Kesehatan occurred from January to September. Thus far, the hospital’s response has been limited to revising the pending claims. Consequently, the implementation of appropriate management strategies is deemed essential in addressing these cases. Purpose: This study aims to analyze the management of inpatient pending BPJS claims at Mawar General Hospital Banjarbaru using the POAC (Planning, Organizing, Actuating, Controlling) framework. Method: This research employed a qualitative approach. The informants consisted of one JKN coordinator, two claim entry officers and one internal claim verification physician. The research instruments comprised observation guidelines and interview protocols. Data analysis was conducted through data collection, data reduction, data presentation and the drawing and verification of conclusions. Discussion: The findings indicate that Mawar General Hospital Banjarbaru possesses documentation pertaining to the four management functions (Planning, Organizing, Actuating and Controlling), which have been implemented effectively, with the exception of the Organizing function, which remains suboptimal. It is therefore recommended that the hospital establish a formal Work Organizational Structure to serve as a reference for staff in carrying out their responsibilities, expand human resource capacity and provide training programs related to the management of pending claims.