Literature Review: Analysis of the Causes of Pending Claims for Inpatient BPJS Patients to Increase Hospital Revenue in Indonesia
Asih Kundari1*, Budi Aji1, Dwi Sarwani Dri Rejeki2

Pending claims on BPJS Kesehatan services can have an impact on disrupting hospital cash flow. This study aims to determine the factors causing claim delays (claim pending) on BPJS services in the JKN Era. Methods: A systematic literature search was conducted on the Google Scholar and Pubmed databases for articles in the last 7 years. The search was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PICO criteria. Article search with boolean operators with the keywords: ^Pending claim^ AND ^BPJS^ OR ^health insurance^ OR ^claim return^. Results: There were 5 articles that were worthy of systematic review. All articles agreed that the delay in BPJS claims was most often caused by document discrepancies to meet BPJS claim requirements and the lack of completeness of administrative documents for membership or services. This is due to limited insight into BPJS claims, limited human resources in the case-mix team, unclear SOPs, and inadequate facilities and infrastructure. Conclusion: All factors from input and process greatly affect the output in this case the occurrence of BPJS claim delays. To reduce losses and even greater burdens on the Hospital, solutions need to be implemented immediately for each of these components that are still experiencing obstacles.
Keyword: Pending claim, BPJS, health insurance, claim return

Abstract

Pending claims on BPJS Kesehatan services can have an impact on disrupting hospital cash flow. This study aims to determine the factors causing claim delays (claim pending) on BPJS services in the JKN Era. Methods: A systematic literature search was conducted on the Google Scholar and Pubmed databases for articles in the last 7 years. The search was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PICO criteria. Article search with boolean operators with the keywords: ^Pending claim^ AND ^BPJS^ OR ^health insurance^ OR ^claim return^. Results: There were 5 articles that were worthy of systematic review. All articles agreed that the delay in BPJS claims was most often caused by document discrepancies to meet BPJS claim requirements and the lack of completeness of administrative documents for membership or services. This is due to limited insight into BPJS claims, limited human resources in the case-mix team, unclear SOPs, and inadequate facilities and infrastructure. Conclusion: All factors from input and process greatly affect the output in this case the occurrence of BPJS claim delays. To reduce losses and even greater burdens on the Hospital, solutions need to be implemented immediately for each of these components that are still experiencing obstacles.
Keyword: Pending claim, BPJS, health insurance, claim return

Keywords: Pending claim, BPJS, health insurance, claim return

Topic: Interdisciplinary Health Sciences