Factors Causing Pending Claims on BPJS Outpatients at Mutiara Bunda Mother and Child Hospital Year 2024

Abstract

Mutiara Bunda Hospital still has many obstacles in the implementation of BPJS claim verification, one of which is the claim file that is rejected by the verifier or commonly referred to as pending claims. The purpose of this study was to determine the factors causing pending claims in BPJS outpatients at Mutiara Bunda Mother and Child Hospital in 2024. This type of research is analytic observational research with a cross sectional approach. The population was the entire claim file of Mutiara Bunda Hospital outpatients as many as 7,659 and the sample was taken by simple random sampling which amounted to 109 files. Data were obtained from observation using a checklist table. Based on the results of the study obtained, 78 (71.6%) medical records were pending, pending BPJS claims for outpatients at Mutiara Bunda Hospital Padang. 23 (21.1%) pending due to inaccurate ICD 9 action codes, pending due to incomplete claim files 31 (28.4%) pending claims due to regulatory incompatibility as many as 42 (38.5%). The results of statistical tests obtained there is a relationship between the inaccuracy of the ICD 9 action code with pending claims (p value = 1.000 (p <0.05). There is a relationship between incomplete claim files and pending claims (p value = 0.042 (p <0.05). There is a relationship between regulatory incompatibility with pending claims (p value = 0.133 (p <0.05). The conclusion of the research results is that the cause of pending claims is influenced by the inaccuracy of the ICD 9 action code, incomplete claim files and regulatory incompatibility. It is hoped that the implementation of coding will be more thorough for the process of inputting the accuracy of the action code on the medical record file with the code in the INA-CBGs application, and pay more attention to the completeness of the claim file in order to minimize the occurrence of pending claims.