Analysis of Pending BPJS Outpatient Claims to Support the Quality of Health Service Payments at Hospital X

Abstract

BPJS Health claims for outpatient services often encounter obstacles, one of which is claims with pending status. Delays or pending BPJS claims have an impact on the smooth flow of payments, reducing the quality of healthcare services in hospitals. This study aims to analyze the factors causing delays in BPJS outpatient claims and their implications for the quality of health service payments at Hospital X in Bandung. The method used is qualitative with a descriptive approach. Data collection techniques included in-depth interviews with the head of outpatient claims and observation of claims management processes. Total population of outpatient claims that were pending from January to March 2025. The sampling technique used is total sampling, which involves collecting all pending claim data from January to March 2025. The analysis was conducted using the 5M method (Man, Machine, Material, Method, and Money) to identify the factors causing claim delays. The results show that there are several factors causing claims to be pending, including aspects related to man, machine, material, and method. In this case, improvements are needed in various aspects to support the quality of healthcare payments in hospitals optimally.