Design of a Web-Based Internal Claim Audit Application in the Casemix Unit in a Hospital to Minimize Pending Claims
DOI:
https://doi.org/10.47701/yb89e038Keywords:
BPJS, Casemix, Coding Audit, Pending Claims, Web-Based SystemAbstract
The Casemix Unit plays a strategic role in the submission and reimbursement of healthcare service claims for BPJS Kesehatan participants. Nevertheless, many hospitals continue to experience pending claims due to administrative errors, incomplete documentation, coding inaccuracies, prolonged verification processes, policy changes, and limited integration of information systems. This study aimed to design and evaluate a web-based internal claim audit application to improve verification effectiveness and reduce pending claims in the Casemix Unit. This research adopted a Research and Development (R&D) approach using the Borg and Gall model and was conducted over one year at RSU Prof. Dr. M. A. Hanafiah Batusangkar, where an increasing number of pending claims was identified in 2024. System evaluation was carried out through usability assessment, and comparative observation of the claim audit process before and after prototype implementation. The results demonstrated that all application features functioned according to system requirements. Implementation of the application contributed to improved operational efficiency, enhanced accuracy in document and coding verification, and faster claim review time compared to the previous manual process. The application includes document completeness verification, coding validation, claim status monitoring, and AI-assisted early detection of potential errors with corrective recommendations. These findings indicate that the system is feasible and capable of supporting a more structured and consistent internal audit process. The study concludes that the application has strong potential to improve claim management quality and support hospital financial sustainability. Future studies should conduct broader implementation, integrate the system with hospital information systems and BPJS platforms, and perform long-term quantitative evaluations of its effectiveness.
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1. Kesehatan B. Peraturan BPJS Kesehatan Nomor 7 Tahun 2018 tentang Pengelolaan Administrasi Klaim Fasilitas Kesehatan dalam Penyelenggaraan Jaminan Kesehatan. 2018.
2. Andani L, Jati SP, Agushybana F. Analysis of Casemix Team Performance in the Successful Verification of National Health Insurance Claims at Hospital XZapia, G., Atina Husnayayin and Desy Eka Citra Dewi (2024) “Karakteristik Dan Langkah-Langkah Metode Penelitian,” Jurnal Ilmiah Pendidikan. Indones J Glob Heal Res. 2024;6(4):2123–34.
3. Zalukhu LA, Permanasari VY. Scoping Review: Factors Causing Claim Pending in Indonesian Hospitals. J Heal Sains. 2025;6(9):252–62.
4. Gunawan E, Rhamadan RS. Analysis of Pending BPJS Outpatient Claims to Support the Quality of Health Service Payments at Hospital X. :181–91.
5. Setiawan AP, Setiatin S, Nuraeni YA. Analisis Penyebab Penundaan Klaim BPJS Kesehatan Pasien. J Ilm Perekam Dan Inf Kesehat Imelda. 2025;10(2):220–9.
6. Ayu Putri NK, Karjono K, Uktutias SA. Analisis Faktor-Faktor Penyebab Keterlambatan Pengajuan Klaim BPJS Kesehatan Pasien Rawat Inap Di RSUD Dr. R. Sosodoro Djatikoesoemo Bojonegoro. J Manaj Kesehat Yayasan RSDr Soetomo. 2019;5(2):134.
7. Rizka Maisaroh A, Lalu Sulaiman, Sismulyanto. Faktor Pending Klaim BPJS Di Rumah Sakit Umum Daerah Provinsi NTB. J Kesehat Qamarul Huda. 2024;12(1):42–7.
8. Anton Susanto, Galih Maheswari Candraningtyas, Agus Trijono. Akurasi Pengkodean Diagnosis dan Prosedur Medis serta Implikasinya terhadap Klaim JKN di RSUD Pandan Arang. J Ilm Kedokt dan Kesehat. 2025;4(3):306–17.
9. Courage Oko-Odion, Onyenum Ruth Udoh. Leveraging technology in internal audit processes for streamlined management and risk oversight. Int J Sci Res Arch. 2024;13(2):3077–100.
10. Nikitha Edulakanti. Preventing Leakage in Claims Management: A Governance Model for Detecting Errors, Fraud, and Process Gaps. Comput Fraud Secur. 2025;1241–50.
11. Irmawati Mathar, Mertisa Dwi Klevina. Reducing Pending Claims In Indonesia’s National Health Insurance System: Evidence From A Standardized Manual Administration Intervention. J Ris Rumpun Ilmu Kesehat. 2025;4(1):473–84.
12. Of Q, Record M, Affects D, Diagnosis OF, In C, In I cbgs C. Indonesian Journal of Global Health Research. Indones J Glob Heal Res. 2019;2(4):3237–42.
13. Perdana A, Dewi S, Farhana NA, Febrian D. Comparative Analysis of SDLC and R&D Methods in System Development: A Case Study of Integrity Zone Management System. Sinkron. 2025;9(4):3197–209.
14. Islayem R, Gebreab S, AlKhader W, Musamih A, Salah K, Jayaraman R, et al. Using large language models for enhanced fraud analysis and detection in blockchain based health insurance claims. Sci Rep. 2025;15(1):1–26.
15. Zapia G, Atina Husnayayin, Desy Eka Citra Dewi. Karakteristik Dan Langkah-Langkah Metode Penelitian. J Ilm Pendidik Dasar. 2024;9:490–501.
16. Haq MA, Werdani KE. Analisis Penyebab Pending Klaim Berkas Bpjs Kesehatan Pasien Rawat Inap Di Rumah Sakit Nirmala Suri. Prepotif J Kesehat Masy. 2025;9(1):765–74.
17. Kurniawan D, Passarella R, Fardinelly S, Anggraini FH, Mattjik HA, Rahmayuni S. Implementasi User Centered Design dan Software Requirements Specification pada Perancangan Website. J Algoritm. 2024;21(1):343–54.
18. Gustina Z, Husnayayin A, Eka D, Dewi C. Karakteristik, Langkah-Langkah, Research And Development, Pendidikan. 2024;09:490–501.
19. Neamatollahi P, Hadi M, Naghibzadeh M. Simple and Efficient Pattern Matching Algorithms for Biological Sequences. IEEE Access. 2020;8:23838–46.
20. Shariatnia S, Ziaratban M, Rajabi A, Salehi A, Abdi Zarrini K, Vakili M. Modeling the diagnosis of coronary artery disease by discriminant analysis and logistic regression: a cross-sectional study. BMC Med Inform Decis Mak [Internet]. 2022;22(1):1–10. Available from: https://doi.org/10.1186/s12911-022-01823-8
21. Istiqomah N, Abdussalaam F, Yunengsih Y. Implementasi Sistem Informasi Verifikasi Klaim BPJS Pasien IGD Menggunakan Metode Agile. J Teknol Sist Inf dan Apl. 2024;7(2):435–44.
22. Hosizah H, Puspita Ningsih K, Nisak UK, Widjaja L. Audit Kode Klinis Pasien Rawat Inap Jaminanan BPJS Kesehatan Di Rumah Sakit Tipe C Dan D Wilayah DIY. J Ilm Perekam dan Inf Kesehat Imelda. 2024;9(2):189–99.
23. Uzzaman A. Federated Learning–Driven Real-Time Disease Surveillance for Smart Hospitals Using Multi-Source Heterogeneous Healthcare Data. ASRC Procedia Glob Perspect Sci Scholarsh. 2025;01(01):1390–423.
24. Syahira N, Unit DI, Rumah C, Blitar SX. Strategi Optimalisasi Klaim Jaminan Kesehatan Nasional Di Unit Casemix Rumah Sakit “X” Blitar. J ARSI Adm Rumah Sakit Indones. 2024;10(2).
25. Retno D, Ningsih U, Afiah N, Makassar UN, Klaim P. Jurnal Keuangan dan Manajemen Terapan Analis Sitem Mutu Pengendalian Jurnal Keuangan dan Manajemen Terapan. 2025;6(3):604–14.
26. Finda Sri Wahyuni, Amarin Yudhana, Wening Palupi Dewi. Analysis Of Accuracy In Determining Diagnosis Coding And Completeness Of Claim Files For Pending Claims Bpjs Kesehatan Inpatient Services Uobk Simpang Lima Gumul Rsud Kediri District. J Hosp Manag Serv. 2024;6(1):6–12.
27. Tarukallo NMS. Strategi Manajemen Penanganan Klaim Pending Bpjs Studi Kualitatif Di Ruang Rawat Inap Penyakit Dalam Di Rsud Pongtiku Toraja Utara. Syntax Lit ; J Ilm Indones. 2025;10(5):5378–96.
28. Meiningtyas A, Maulina FC. Faktor-faktor Penyebab Pending Klaim Peserta Jaminan Kesehatan Nasional di Rumah Sakit Pusat Pertamina. J Manaj Inf Kesehat Indones [Internet]. 2025;1(13):1. Available from: https://jmiki.aptirmik.or.id/jmiki/article/view/660
29. Sagita D, Yunengsih Y, Abdussalaam F. Desain Sistem Informasi Klaim BPJS Pasien Penyakit Dalam dengan Metode V Model. J Teknol Sist Inf dan Apl. 2024;7(2):426–34.
30. Praja NI, Ferianasari IW, Jaqualina C. The Effectiveness of Health BPJS Claim Discrepancies Against Health Service Standards in Indonesia. FIRM J Manag Stud. 2024;9(1):164.
31. Klevina MD, Mathar I, Tinggi S, Kesehatan I, Husada B, Tinggi S, et al. Factors Contributing to Pending Inpatient Claims in The National Health Insurance Program : A Systematic. 2026;5(1):94–107.
32. Oktamianiza O, Rahmadhani R, Yulia Y, Ilahi V, Putri KA, Juwita FS. Penyebab Pending Klaim Berdasarkan Aspek Diagnosis dan Ketepatan Kode Diagnosis. J-REMI J Rekam Med dan Inf Kesehat. 2024;5(4):282–7.
33. Nenny O, Sinta N. Evaluasi Sistem Casemix Dalam Proses Klaim BPJS: Studi Kualitatif di RS Paru Ario Wirawan Salatiga Nenny Oktarina 1í ½í ¶ , Sinta Novratilova 2. Jurnalners [Internet]. 2025;9:3150–4. Available from: http://journal.universitaspahlawan.ac.id/index.php/ners
34. Anggraeni RF, Prakoso BH, Alfiansyah G, Mudiono DRP. Evaluation of Hospital Management Information System (HMIS) Implementation in the Registration Unit from the Perspectives of Technology, Human, and Organization. Int J Healthc Inf Technol. 2024;2(1):31–9.
35. Suwani, Teguh Prasetyo, Diah Arimbi AJ. Kerahasiaan Medis dan Data Pasien Dalam Catatan Rekam Medis Elektronik. 2022;2626–34.
36. Sbodio ML, López V, Hoang TL, Brisimi T, Picco G, Vejsbjerg I, et al. Collaborative artificial intelligence system for investigation of healthcare claims compliance. Sci Rep [Internet]. 2024;14(1):1–17. Available from: https://doi.org/10.1038/s41598-024-62665-0
37. Fauzia Laili, Siti Aminah, Siswi Wulandari, Khofifah Rafika, Nadia Vivi K. The Efficacy of Utilizing BPJS Health Claim Big Data on the Accuracy of Diagnosis Coding in Type B Hospital Medical Records. Res Evid Knowl Adm Manag — Med Electron Data Inf Syst. 2025;1(2):34–44.
38. Wulandari M, Novriyanti T, Purwadhi P, Widjaja YR. Implementasi Strategi Transformasi Digital dalam Meningkatkan Kualitas Pelayanan di Rumah Sakit: Studi Kualitatif. Innov J Soc Sci Res [Internet]. 2025;5(1):1415–27. Available from: https://j-innovative.org/index.php/Innovative/article/view/17847
39. Efendy I, Nyorong M, Amirah A, Sari F. National Health Insurance (JKN) Mobile Application Use Towards Satisfaction of Participants of the Health Social Security Implementing Agency (BPJS) in Madani Hospital in Medan City. J Med Heal Stud. 2022;3(1):26–34.
40. Pranggoro K, Okta ADK, Wastuaji A, Mais RG, Sunarsih U. Peran Digitalisasi Dalam Pencegahan Fraud: Studi Pada Bpjs Rumah Sakit Swasta. RIGGS J Artif Intell Digit Bus. 2025;4(2):1316–22.
41. Ayu Purwasih D, Abdussalaam F. Perancangan Sistem Informasi Klaim Bpjs Kesehatan Rawat Jalan Berbasis Web Di Rsud Koja Jakarta Utara. INFOKOM (Informatika & Komputer) [Internet]. 2024;12(2):18–29. Available from: https://journal.piksi.ac.id/index.php/INFOKOM/article/view/1298
42. Maulia P, Sartika I, Ani N, Rahardjo B. Educational Interventions and Digital Innovation for Improving BPJS Inpatient Claims. J Educ Dev [Internet]. 2025;13(1):50–9. Available from: https://journal.unnes.ac.id/journals/jed/article/view/24372
43. Emilio. The Effect of The Role of Intertnal Audit Units on The Performance of Insurance Claim Services and Management System With Fraud Prevention as Intervening Variabeles in Tarumajaya Hospital. Eff Role Intern Audit Units Perform Insur Claim Serv Manag Syst With Fraud Prev AS Interv Var Tarumajaya Hosp. 2022;3(8.5.2017):2003–5.
44. Hasibuan A, Girsang E, Nasution SLR. Performance Evaluation of Internal Verifier in Reducing Pending Inpatient Claims of BPJS Kesehatan at Muhammadiyah Hospital North Sumatra 2022. Contag Sci Period J Public Heal Coast Heal. 2025;7(2):343.
45. Nuriyah Nuriyah, Muhammad Akbar, Reza Fahrepi. Health Economic Evaluation in Healthcare Management : A Systematic Review of Cost-Effectiveness Studies in Hospital Operations. J Publ Sist Inf dan Manaj Bisnis. 2025;4(3):350–9.
46. Yunita R, Kasim F, Ginting KA. Analisis Penerapan Sistem Aplikasi S-Klaim Dalam Rangka Penerapan Standar Klaim BPJS Di Charitas Hospital Belitang Tahun 2024 Analysis of The Implementation of The S-Claim Application System In The Context of The Implementation of BPJS Claim Standards In . 2024;(c):15–24.
47. Naga Srinivasulu Gaddapuri. Digital Twin Governance: IoT-Driven Real-Time Regulatory Auditing in Smart Hospital Architectures. Comput Fraud Secur. 2025;1462–70.
48. Rahmi SA, Sidik TA. Analisis Strategi Manajemen Klaim dalam Menekan Risiko Fraud Asuransi Kesehatan : Analisis Systematic Literature Review. 2025;8(2):104–11.
49. Tsang JY, Peek N, Buchan I, Van Der Veer SN, Brown B. Systematic review and narrative synthesis of computerized audit and feedback systems in healthcare. J Am Med Informatics Assoc. 2022;29(6):1106–19.
50. Marwanto, Soepriyanto G. The influence of audit quality, the use of information technology, management support, and the application of guidelines on the effectiveness of internal audit in preventing and detecting fraud in hospitals. Edelweiss Appl Sci Technol. 2025;9(3):1819–42.
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