Pending Inpatient Claims in Indonesia's National Health Insurance System: Implications of INA-CBGs Revisions for Claim Reimbursement
DOI:
https://doi.org/10.56338/mppki.v9i9.9181Keywords:
Claims Management, National Health Insurance, INA-CBGs, Pending Claims, ReimbursementAbstract
Introduction: This study examined pending inpatient claims under Indonesia’s National Health Insurance (BPJS) for the July–December 2025 claim period. A simple random sample of 239 pending claims was included, with claim revision followed by final verification. The study aimed to identify administrative, medical, and coding-related factors contributing to pending claims; assess changes in INA-CBGs categorisation and reimbursement following claim revision; and describe the implications for claims management.
Methods: This quantitative descriptive case study retrospectively reviewed pending inpatient claims submitted to BPJS. A simple random sample of 239 eligible claims was selected from 595 pending claims using random-number generation in Microsoft Excel. Data were extracted from claim documents and analysed descriptively to identify changes in Case Main Group (CMG), Severity Level, and reimbursement values before and after claim revision.
Results: Among the 239 pending inpatient claims, administrative factors accounted for 46%, followed by medical factors (37%) and coding-related factors (17%). CMG changed in three claims, whereas Severity Level changed in seven claims, comprising six downgrades and one upgrade. Nine claims showed changes in INA-CBGs reimbursement, with a net decrease of IDR 19,378,800 (26.74%) compared with the pre-revision values.
Conclusion: Pending BPJS inpatient claims had administrative and financial implications extending beyond payment delays to changes in INA-CBGs classification and reimbursement. Strengthening clinical documentation, adherence to appropriate coding practices, and claims governance may improve reimbursement accuracy and support the sustainability of hospital financing.
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