Analysis of Individual Characteristics of Employee’s Performance at Regional Hospital dr. Soebandi Jember on the Case of BPJS Inpatient Pending Claim

Abstract

JKN program is mandatory social health insurance for all Indonesian citizens. JKN claims are submitted monthly by the hospital to reimburse the service fee provided to its participants. Pending claims occur because the submitted claims still get confirmation from the Social Security Administrator for Health. In March-May 2021, 234 pending claims were found out of 1934 total submitted inpatient claims by RSD dr. Soebandi Jember. This incident cannot be separated from the performance of claim officers. According to Gibson's theory, performance could be influenced by individual variables. This study aims to analyze the determinants of inpatient pending claims based on individual characteristics. This research a qualitative using depth interviews, observation, and documentation. The result shows pending claims caused by an unmatched ability of coders and physicians in charge of the patients, the implementation of internal verification has not been maximized and different perceptions regarding claims regulation between coders and BPJS verifiers. To solve the problem, an in-charge officer for the completeness of medical records in each inpatient room is needed, implement one-stop administration system, increase the understanding and accuracy of coder, and communicating with BPJS to equalize claims regulation perceptions.