Metode Eksploratif Kualitatif Formal Untuk Mengetahui Terjadinya Pending Klaim JKN Kasus Rawat Inap Dalam Proses Klaim Elektronik di RSUD X

Formal Qualitative Explorative Method to Find Out the Occurrence of Pending JKN Claims in Inpatient Cases in the Electronic Claims Process at X Regional Hospital

Abstract

Introduction: The electronic claim system is designed to improve efficiency in healthcare service reimbursement. However, only 75% of inpatient claims were submitted during its initial implementation, showing a decline compared to previous months. This was accompanied by a high percentage of pending claims, indicating system, documentation, and workflow issues. This study aims to identify the factors contributing to pending inpatient claims in the electronic claim process and to propose improvement strategies.

Methods: This study used a qualitative exploratory method with a case study approach. Data were collected through interviews, observations, and document reviews, involving informants selected by purposive sampling. The data were analyzed using thematic analysis and visualized using a fishbone diagram, which grouped causes into man, method, machine, material, and money factors.

Results: Claims for inpatient cases in November 2022 were only 75% or 1093 out of a total of 1443 inpatients. There was a decrease in the number of claims submitted when compared to previous months, namely in the range of 80-90% of inpatients. Pending claims at Dr Soedarso Regional Hospital in November 2022 are 367 files or 33.5% of the total claims submitted. The largest group of cases where pending inpatient claims occurred in November 2022 was indications of hospitalization and the need for confirmation from the DPJP (doctor in charge of the patient), namely 138 claims or 36.7%. This was followed by the case group of ICD-10 and ICD-9-CM coding rules and reselection of the main diagnosis with 109 claims or 29.7%. The third largest group of cases was incomplete claim support, with 96 claims or 26.2%. Then there were 19 administrative errors in claims, or 5.1%, and finally, errors in INACBG grouping were 5 claims, or 1.4%.Discussion: Pending claims occur due to multiple interconnected factors. Human resource limitations, incomplete documents, ineffective verification flow, system instability, and lack of funding for training and infrastructure all contribute. Improving workflow, enhancing verification, and digitizing supporting documents are necessary to reduce claim delays