GAMBARAN FAKTOR PENYEBAB PENDING KLAIM PADA KASUS PNEUMONIA RAWAT INAP DIRUMAH SAKIT UMUM HIKMAH MAKASSAR TAHUN 2025

Abstrak

Latar Belakang: Pending klaim BPJS Kesehatan dapat menghambat pembayaran klaim rumah sakit, terutama akibat ketidaktepatan kaidah pengodean, ketidaksesuaian standar pelayanan, dan ketidakpatuhan terhadap regulasi. Penelitian ini bertujuan mengidentifikasi faktor-faktor tersebut pada klaim pneumonia rawat inap di Rumah Sakit Umum Hikmah Makassar tahun 2025. Metode: Penelitian observasional dengan pendekatan deskriptif kuantitatif menggunakan 61 berkas klaim pneumonia yang mengalami pending, dipilih melalui simple random sampling. Data dikumpulkan melalui observasi menggunakan checklist dan dianalisis secara univariat dengan distribusi frekuensi dan persentase. Hasil: Sebanyak 35 berkas (57,4%) telah menerapkan kaidah coding dengan tepat, sedangkan 26 (42,6%) belum tepat. Sebanyak 40 berkas (65,6%) sesuai standar pelayanan dan 21 (34,4%) belum sesuai. Sementara itu, 38 berkas (62,3%) patuh terhadap regulasi dan 23 (37,7%) belum patuh. Kesimpulan: Ketidaktepatan coding, ketidaksesuaian standar pelayanan, dan ketidakpatuhan terhadap regulasi masih ditemukan pada berkas pending klaim BPJS. Oleh karena itu, diperlukan peningkatan kompetensi coder, kelengkapan dokumentasi rekam medis, dan kepatuhan terhadap regulasi untuk mendukung kelancaran proses klaim.

Background: Pending claims in the Indonesian National Health Insurance (BPJS Kesehatan) system may delay hospital reimbursements. Contributing factors include coding inaccuracies, service standards, and regulatory compliance. Objective: To describe factors associated with pending inpatient pneumonia claims at Hikmah General Hospital Makassar in 2025. Methods: This descriptive quantitative study used an observational approach involving 61 pending inpatient pneumonia claim files selected through simple random sampling. Data were collected using an observation checklist and analyzed using frequency distributions and percentages. Results: Coding guidelines were accurately implemented in 35 files (57.4%), while 26 (42.6%) were inaccurate. Service standards were met in 40 files (65.6%) and unmet in 21 (34.4%). Regulatory compliance was observed in 38 files (62.3%), while 23 (37.7%) were non-compliant. Inaccurate diagnosis coding was also reported at 67.2%, making it a major factor in pending claims. Conclusion: Coding inaccuracies, unmet service standards, and regulatory non-compliance contribute to pending claims. Improving coder competency, medical record completeness, and regulatory compliance is essential to improve coding accuracy and claim processing.