Latar Belakang: Rumah Sakit Hermina telah menetapkan Peraturan Direktur Utama PT Medika Loka Manajemen Nomor 438 Tahun 2024 tentang Pengelolaan Anti Fraud, Administrasi Klaim dan Pembinaan Jaminan Kesehatan Nasional sebagai pedoman dalam memperkuat tata kelola pelayanan JKN. Salah satu ruang lingkup kebijakan tersebut adalah pengelolaan administrasi klaim melalui proses koding dan verifikasi internal sebagai titik kendali sebelum pengajuan klaim kepada BPJS Kesehatan. Implementasi yang belum optimal pada kedua proses tersebut dapat menyebabkan klaim pending, klaim tidak layak, serta meningkatkan potensi fraud administratif. Variasi tingkat klaim pending antar rumah sakit menunjukkan adanya perbedaan implementasi kebijakan pada tingkat operasional. Metode: Penelitian ini menggunakan pendekatan kualitatif dengan model implementasi kebijakan Van Meter dan Van Horn sebagai kerangka analisis yang meliputi sumber daya, komunikasi, karakteristik organisasi pelaksana, komitmen pelaksana, kondisi lingkungan, dan kinerja implementasi. Data dikumpulkan melalui wawancara mendalam terhadap 18 informan dan telaah dokumen di RS Hermina X dan RS Hermina Y, kemudian dianalisis secara tematik dengan triangulasi sumber dan metode. Hasil: Implementasi kebijakan pada aspek pengelolaan administrasi klaim menunjukkan perbedaan antara kedua rumah sakit. RS Hermina Y menerapkan verifikasi internal berlapis, monitoring berbasis dashboard, evaluasi rutin, serta adaptasi yang lebih cepat terhadap perubahan regulasi. Sebaliknya, RS Hermina X masih menghadapi kendala pada standardisasi verifikasi internal, pemanfaatan sistem informasi, monitoring, dan koordinasi lintas profesi. Perbedaan implementasi tidak ditentukan oleh jumlah sumber daya, tetapi oleh kemampuan organisasi mengelola sumber daya, membangun komunikasi, memperkuat koordinasi, serta menumbuhkan komitmen pelaksana. Belum adanya standar operasional prosedur verifikasi internal yang seragam di tingkat grup turut menyebabkan variasi implementasi antar rumah sakit. Kesimpulan: Implementasi Kebijakan Pengelolaan Anti Fraud, Administrasi Klaim dan Pembinaan JKN pada aspek pengelolaan administrasi klaim dipengaruhi oleh sumber daya, komunikasi, karakteristik organisasi, komitmen pelaksana, dan kondisi lingkungan. Keberhasilan implementasi lebih ditentukan oleh kemampuan organisasi mengintegrasikan faktor-faktor tersebut melalui kepemimpinan operasional, pengendalian internal, dan standardisasi proses verifikasi internal dibandingkan oleh ketersediaan sumber daya semata. Penguatan standar verifikasi internal, optimalisasi sistem informasi, dan monitoring berkelanjutan diperlukan untuk meningkatkan kualitas administrasi klaim serta mendukung pencegahan potensi fraud administratif.

Background: Hermina Hospitals established the Board of Directors Regulation No. 438 of 2024 on Anti-Fraud, Claims Administration, and National Health Insurance (NHI) Development to strengthen JKN governance. This study focused on the implementation of the claims administration component, particularly coding and internal verification, as key control points before claims are submitted to BPJS Kesehatan. Variations in pending claim rates among hospitals indicate differences in policy implementation. Methods: This qualitative study applied the Van Meter and Van Horn policy implementation model. Data were collected through in-depth interviews with 18 informants and document reviews at Hermina Hospital X and Hermina Hospital Y. The data were analyzed using thematic analysis with source and method triangulation. Results: The implementation of the Anti-Fraud, Claims Administration, and National Health Insurance Development Policy, particularly in the claims administration component, differed between the two hospitals. Hermina Hospital Y implemented a multilayered internal verification system, utilized a monitoring dashboard, conducted routine evaluation meetings, and demonstrated greater adaptability to changes in BPJS Kesehatan regulations. In contrast, Hermina Hospital X continued to encounter challenges in standardizing internal verification, optimizing information technology utilization, conducting monitoring activities, and strengthening interdisciplinary coordination. These differences were reflected in the lower pending claim rates achieved by Hermina Hospital Y compared with Hermina Hospital X. Factors influencing policy implementation included resources, communication, characteristics of implementing organizations, implementers' commitment, and environmental conditions. Conclusion: The implementation of the Anti-Fraud, Claims Administration, and National Health Insurance Development Policy, particularly in the claims administration component, was influenced by resources, communication, characteristics of implementing organizations, implementers' commitment, and environmental conditions, as described in the Van Meter and Van Horn policy implementation model. Strengthening standardized internal verification, optimizing information technology, enhancing interdisciplinary coordination, and conducting continuous monitoring and evaluation are essential to improving the quality of claims administration and supporting the prevention of administrative fraud within the NHI program continuous monitoring and evaluation are essential to prevent administrative fraud and improve the quality of NHI claims management.

Rumah Sakit Umum (RSU) Aisyiyah Muntilan memiliki tingkat ketergantungan pendapatan yang sangat tinggi terhadap Program Jaminan Kesehatan Nasional (JKN) untuk pasien rawat inap, di mana proporsinya konsisten berada di atas 80% hingga mendekati 90%. Namun, terdapat kesenjangan antara urgensi manajemen untuk mempercepat proses penagihan guna menjaga stabilitas arus kas (cashflow) dengan realitas operasional di lapangan yang sering terhambat oleh masalah kelengkapan rekam medis, kesiapan sistem informasi, dan tingginya berkas yang ditunda (pending). Penelitian ini bertujuan untuk mengevaluasi implementasi pengelolaan berkas klaim pasien rawat inap JKN dari hulu ke hilir di RSU Aisyiyah Muntilan menggunakan kerangka Teori Donabedian (Struktur, Proses, Dampak), serta menganalisis tata kelola pada berkas klaim yang berstatus layak bayar maupun pending. Penelitian ini merupakan penelitian kualitatif dengan pendekatan riset operasional. Pengumpulan data primer dan sekunder dilakukan melalui wawancara mendalam, Focus Group Discussion (FGD), observasi, serta telaah dokumen terhadap para informan yang dipilih melalui teknik purposive sampling dari berbagai unit terkait. valuasi implementasi pengelolaan klaim menunjukkan kendala struktural berupa ketiadaan SPO terintegrasi, lambatnya perangkat keras SIRS, ketiadaan integrasi (full bridging) ke portal e-Claim, serta pelimpahan tugas pengisian resume medis dari DPJP ke perawat. Pada evaluasi tata kelola, berkas berstatus layak didominasi oleh kasus Severity Level I (79%) yang mempercepat penagihan namun memunculkan risiko kerugian finansial akibat undercoding. Sementara itu, berkas berstatus pending dikembalikan oleh BPJS akibat masalah Standar Pelayanan (46%), Kaidah Koding (31%), dan Kelengkapan Dokumen (23%), yang dipicu oleh ketiadaan kriteria objektif di rekam medis, perbedaan terminologi klinis, lamanya rujukan patologi anatomi eksternal, dan dokumen tercecer akibat penggunaan sistem cetak-pindai. Pengelolaan klaim di RSU Aisyiyah Muntilan masih menghadapi hambatan struktural dan teknis dari hulu hingga hilir. Rumah sakit disarankan untuk mengimplementasikan integrasi penuh (full bridging) antara SIRS dan e-Claim, menerapkan fitur isian wajib (mandatory field), memaksimalkan fungsi peringatan otomatis (alert system), serta menyusun "Kamus Jembatan Terminologi" untuk menyelaraskan istilah klinis DPJP dengan kaidah koding ICD-10.

Aisyiyah Muntilan General Hospital (RSU) has a very high revenue dependence on the National Health Insurance (JKN) program for inpatients, with proportions reaching 80% to 90%. The hospital targets the acceleration of claim billing to maintain cash flow stability, but the reality in the field is still hampered by fragmentation and process inefficiencies from upstream to downstream. This study aims to evaluate the implementation of JKN inpatient claim management, analyze the governance of eligible claims, and analyze the governance of pending claims at RSU Aisyiyah Muntilan. This is a qualitative study using an operational research approach. Data were collected through in-depth interviews, Focus Group Discussions (FGD), observations, and document reviews with informants selected via purposive sampling from various related units. The analysis was conducted using the Donabedian Theory framework (Structure, Process, Outcome). he evaluation of claim management implementation indicates structural constraints in the form of the absence of integrated Standard Operating Procedures (SOP), slow Hospital Information System (SIRS) hardware, lack of full bridging to the e-Claim portal, and the delegation of medical resume filling tasks from attending physicians (DPJP) to nurses. In the governance evaluation, eligible claims are dominated by Severity Level I cases (79%), which accelerates billing but raises the financial risk of undercoding. Meanwhile, pending claims were returned by BPJS due to issues with Service Standards (46%), Coding Rules (31%), and Document Completeness (23%), which were triggered by the lack of objective criteria in medical records, clinical terminology differences, long waiting times for external anatomical pathology referrals, and scattered documents due to the use of a print-scan system. Claim management at RSU Aisyiyah Muntilan still faces structural and technical barriers from upstream to downstream. The hospital is advised to implement full bridging between SIRS and e-Claim, apply mandatory field features, maximize the function of automatic alert systems, and compile a "Terminology Bridge Dictionary" to align DPJP's clinical terms with ICD-10 coding rules.

Penundaan pembayaran klaim (pending claim) Jaminan Kesehatan Nasional (JKN) oleh BPJS Kesehatan mengakibatkan gangguan arus kas rumah sakit dan peningkatan beban kerja petugas. Rumah Sakit Umum Menteng Mitra Afia (RSU MMA) merupakan rumah sakit swasta kelas C dengan proporsi pasien rawat inap JKN lebih dari 98%, sehingga tingginya angka klaim pending berisiko menimbulkan beban finansial dan administratif yang serius. Hingga saat ini, belum dilakukan analisis mendalam mengenai kegagalan dalam proses pengelolaan klaim yang berpotensi menyebabkan pending. Penelitian ini bertujuan untuk menganalisis potensi penyebab klaim pending rawat inap JKN dalam setiap tahapan proses pengajuan klaim dan mengembangkan sistem perbaikan dalam rangka mencegah, menangani, dan memprediksi klaim pending rawat inap. Penelitian ini menggunakan metode kualitatif dengan pendekatan operational research yang dilakukan pada bulan Mei-Oktober 2025. Pengumpulan data dilakukan melalui telaah dokumen klaim pending Januari 2024-Agustus 2025, wawancara mendalam dengan 11 informan, observasi partisipatif, dan Focus Group Discussion (FGD). Analisis risiko dilakukan menggunakan metode FMEA untuk menentukan prioritas masalah berdasarkan nilai Risk Priority Number (RPN). Hasil penelitian menunjukkan bahwa klaim pending rawat inap mengalami lonjakan signifikan pada Agustus-Oktober 2024 dengan puncaknya sebanyak 77,4% di bulan September. Pada tahun 2025, klaim pending menurun tetapi tetap fluktuatif di angka 6,5%-21%. Penyebab klaim pending didominasi oleh konfirmasi indikasi rawat inap, konfirmasi diagnosis, dan ketidaklengkapan berkas penunjang. Berdasarkan perhitungan RPN, tiga failure mode dengan prioritas tertinggi adalah: (1) ketidaksesuaian indikasi rawat inap pada proses asesmen di poliklinik; (2) diagnosis tidak sesuai kriteria dan tata laksana spesifik belum sesuai pada pelayanan rawat inap; dan (3) koding diagnosis belum sesuai atau membutuhkan konfirmasi pada verifikasi internal Casemix (RPN 24). Identifikasi akar masalah menunjukkan kurangnya pemahaman dan kesadaran Dokter Penanggung Jawab Pelayanan (DPJP) terhadap regulasi BPJS yang dinamis, tidak adanya penyampaian data penyebab klaim pending secara rutin kepada DPJP, belum adanya mekanisme reward and punishment terkait kelengkapan pengisian resume medis, serta beban kerja verifikator yang tinggi. Faktor eksternal seperti pengetatan danperubahan regulasi BPJS Kesehatan juga berkontribusi terhadap terjadinya klaim pending. Sistem penanggulangan klaim pending yang dikembangkan berupa prototipe pencegahan dengan “clean claim,” penanganan menggunakan register klaim pending, serta prediksi klaim pending mberupa prediktor risiko pending.

Delayed payment of claims (pending claims) under the National Health Insurance (JKN) program by BPJS Kesehatan disrupts the hospital’s cash flow and increases the workload of claim management staff. Menteng Mitra Afia General Hospital (RSU MMA), a Class C private hospital with more than 98% of its inpatient population covered by JKN, is highly vulnerable to financial and administrative burdens caused by high pending claim rates. To date, no in-depth analysis has been conducted to identify failures within the claim management process that potentially lead to pending claims. This study aims to analyze the potential causes of inpatient JKN claim pending at each stage of the claim submission process and develop an improvement system to prevent, manage, and predict pending inpatient claims. This research employed a qualitative method with an operational research approach conducted from May to October 2025. Data were collected through a review of pending claim documents from January 2024 to August 2025, in-depth interviews with 11 informants, participatory observation, and Focus Group Discussions (FGD). Risk analysis was carried out using the FMEA method to determine priority issues based on the Risk Priority Number (RPN). The results showed a significant increase in inpatient pending claims during August–October 2024, peaking at 77.4% in September. In 2025, pending claims decreased but remained fluctuating at 6.5%–21%. The dominant causes of pending claims included confirmation of inpatient indication, confirmation of diagnosis, and incomplete supporting documents. Based on RPN calculations, the three highest-priority failure modes were: (1) inappropriate inpatient indication assessment at the outpatient clinic; (2) diagnosis not meeting clinical criteria and specific management standards during inpatient care; and (3) inaccurate or unconfirmed diagnosis coding during internal casemix verification (RPN 24). Root cause analysis identified limited understanding and awareness of attending physicians (DPJP) regarding dynamic BPJS regulations, lack of routine feedback on pending claim causes, absence of a reward-and-punishment mechanism for completeness of medical resumes, and high workload among internal verificator. External factors, such as stricter verification and regulatory changes from BPJS Health, also contributed to the occurrence of pending claims. The developed system for managing pending claims consists of a preventive prototype based on a “clean claim” approach, a handling mechanism using a pending claim register, and a pending claim prediction component in the form of a risk predictor for pending claims.

Latar Belakang: RS Hermina Bekasi merupakan rumah sakit swasta dengan layanan unggulan dan potensi pengembangan pasien non-Jaminan Kesehatan Nasional (JKN). Namun, proporsi pasien JKN masih lebih tinggi dibandingkan pasien non-JKN, sehingga diperlukan strategi pemasaran untuk meningkatkan kunjungan pasien non-JKN. Tujuan: Penelitian ini bertujuan menyusun strategi pemasaran untuk meningkatkan kunjungan pasien non-JKN di RS Hermina Bekasi melalui analisis kondisi pemasaran, faktor internal dan eksternal, rumusan strategi, serta indikator keberhasilan. Metode: Penelitian ini menggunakan pendekatan kualitatif dengan metode marketing research berkarakteristik deskriptif dan eksploratif. Informan dipilih secara purposive purposif berdasarkan prinsip kesesuaian dan kecukupan. Data dikumpulkan melalui wawancara mendalam, observasi, telaah dokumen, dan studi literatur. Analisis menggunakan sintesis The Strategy-Formulation Analytical Framework dan The Stages of Building a Marketing Plan Framework. Hasil: RS Hermina Bekasi memiliki kekuatan pada layanan unggulan, dokter spesialis dan subspesialis, teknologi medis, reputasi Hermina, SDM garis depan pelayanan seperti petugas front office, perawat, Staf Fungsional Eksekutif, case manager, farmasi, dan kasir, serta nursing marketing, dan dukungan Hermina Group. Kelemahan meliputi persepsi sebagai rumah sakit BPJS dan ibu-anak, fungsi marketing belum optimal, keterbatasan data pemasaran, digital marketing, proses pelayanan, dan bukti fisik layanan. Peluang berasal dari potensi pasar Bekasi, pasien out of pocket, kerja sama perusahaan dan asuransi, komunitas, kebutuhan layanan spesialistik, serta digital marketing. Ancaman meliputi persaingan rumah sakit swasta, ekspektasi pasien non-JKN, sensitivitas harga, Coordination of Benefit, dan review online. Skor EFE 3,12 dan IFE 3,05 menempatkan RS Hermina Bekasi pada posisi grow and build yang mendukung untuk melakukan strategi pertumbuhan secara intensif dan integratif. Strategi definitif meliputi penguatan layanan unggulan, segmentasi pasar, positioning, kemitraan, pemasaran berbasis data, digital marketing, customer journey, program priority, dan bukti fisik layanan. Kesimpulan:  Strategi pemasaran pasien non-JKN perlu diarahkan pada strategi pertumbuhan terintegrasi antara pemasaran dan pelayanan. Peningkatan pasien non-JKN tidak cukup melalui promosi, tetapi perlu didukung penguatan layanan unggulan, positioning, data pemasaran, digital marketing, nursing marketing, program priority, customer journey, dan evaluasi berbasis indikator.

Background: RS Hermina Bekasi is a private hospital with center of excellence services and potential for developing non-National Health Insurance (non-JKN) patients. However, the proportion of JKN patients remains higher than that of non-JKN patients, indicating the need for a marketing strategy to increase non-JKN patient visits. Objectives: This study aimed to develop a marketing strategy to increase non-JKN patient visits at RS Hermina Bekasi by analyzing current marketing conditions, internal and external factors, strategy formulation, and success indicators. Method: This study used a qualitative approach with a descriptive and exploratory marketing research method. Informants were selected purposively based on the principles of appropriateness and adequacy. Data were collected through in-depth interviews, observation, document review, and literature study. The analysis used a synthesis of The Strategy-Formulation Analytical Framework and The Stages of Building a Marketing Plan Framework. Results: RS Hermina Bekasi has strengths in center of excellence services, specialist and subspecialist doctors, medical technology, Hermina’s reputation, frontline service personnel including front office staff, nurses, Executive Functional Staff, case managers, pharmacy staff, and cashiers, as well as nursing marketing and support from Hermina Group. Weaknesses include the perception as a BPJS and mother-child hospital, suboptimal marketing functions, limited marketing data, digital marketing, service processes, and physical evidence of services. Opportunities arise from the Bekasi market potential, out-of-pocket patients, partnerships with companies and insurance providers, communities, the need for specialist services, and digital marketing. Threats include competition among private hospitals, high expectations of non-JKN patients, price sensitivity, Coordination of Benefit, and online reviews. The EFE score of 3.12 and IFE score of 3.05 placed RS Hermina Bekasi in the grow and build position, supporting intensive and integrative growth strategies. The definitive strategies include strengthening center of excellence services, market segmentation, positioning, partnerships, data-based marketing, digital marketing, customer journey, Program Priority, and physical evidence of services. Conclusion: The marketing strategy for non-JKN patients should be directed toward an integrated growth strategy between marketing and service delivery. Increasing non-JKN patients cannot rely solely on promotion, but must be supported by strengthening center of excellence services, positioning, marketing data, digital marketing, nursing marketing, Program Priority, customer journey, and indicator-based evaluation.

Penelitian ini merupakan penelitian kualitatif dengan menggunakan metode wawancara mendalam dan telaah dokumen untuk menganalisa penyebab klaim Pending jaminan kesehatan nasional di RS Bakti Timah Karimun Tahun 2022. Hasil penelitian ini nantinya diharapkan dapat menjadi acuan untuk perbaikan layanan dan manajemen klaim jaminan kesehatan nasional di RS Bakti Timah Karimun dikemudian hari.