Analysis of Pending Claim Factors through a Total Quality Management Approach at Hospital X Iik Sartika (a*), Nabela Putri Yanuari (a), Syefira Ayudia Johar (b), Julia Pertiwi (b)
(a)Faculty of Health Sciences Jenderal Soedirman University
Jalan dr. Soeparno Grendeng Purwokerto Utara Banyumas
(b)Faculty of Public Health and Health Science Veteran Bangun Nusantara University
Jalan Letjend HUmardani No 1 Sukoharjo
Abstract
Hospitals collaborate with BPJS Kesehatan in providing healthcare services through claims submission and reimbursement processes. One of the persistent challenges for hospitals is pending claims. As of October 2024, the rate of delayed inpatient claims at Hospital X reached 22%. This study aims to identify the factors contributing to pending claims and to formulate policy improvement recommendations using a Total Quality Management (TQM) approach. The research employs a qualitative case study method. Data were collected through in-depth interviews, observations, and document reviews. The findings reveal that the dominant cause of pending claims is inaccurate medical records (75%), followed by incomplete documentation (13%), insufficient supporting examinations (8%), and inadequate therapy evidence (4%). The hospital continues to face challenges in adapting to the digitalization of administrative systems. Policy recommendations are formulated based on implementation stages (audit, human resource training, digitalization, and SOP monitoring) as well as success indicators (reduction of pending claims by ≥-70%, claim disbursement within ≤-14 days, and coding accuracy of ≥-90%).
