STRATEGI MANAJEMEN PENANGANAN KLAIM PENDING BPJS STUDI KUALITATIF DI RUANG RAWAT INAP PENYAKIT DALAM DI RSUD PONGTIKU TORAJA UTARA

Pending claims in the BPJS Kesehatan system are a problem that often occurs in various health facilities, especially hospitals. Medical record files with pending claim status in inpatient illness at Pongtiku Hospital tend to increase, reaching 12% (2019), 28% (2020), 19% (2021), 21% (2022) and 28% in 2023. Pending claims disrupt revenues and affect hospital operational activities. This research is a qualitative research. This study aims to determine the management strategy for handling BPJS pending claims in the Inpatient room of Pongtiku Hospital. Data collection was carried out through observation, in-depth interviews and document review. The results of the study show that the factors causing BPJS pending claims in Internal Medicine Inpatient at Pongtiku Hospital are; incomplete files (67 files) (45.8%), inaccurate coding (43 files) (29.5%), lack of supporting examinations (21 files) (21%), lack of therapeutic evidence (10 files) (6.8%) and misunderstanding between hospital verifiers and BPJS verifiers (5 files) (3.5%). The process of handling pending claims based on Planning, Organization, Actuating and Controlling (POAC) has not been running optimally. This is due to the incompleteness of filling out the BPJS claim requirement file, limited human resources, inadequate facilities and infrastructure, lack of job description, lack of motivation of officers, lack of SOP on the process of handling BPJS pending claims and competency development training and evaluation activities are still rarely carried out. The recommended recommendations are to increase the number of human resources responsible for the BPJS claims management process, Fulfill facilities and infrastructure that support the claims handling process, Create special SOPs related to the process of handling pending BPJS claims, Provide continuous training and competency development for the claims verification team, Provide rewards to officers, Create a periodic monitoring and evaluation system and immediately implement RME (Electronic Medical Records) for inpatients.