Analysis of Post-Claim Verification Findings in the National Health Insurance Program at dr. T.C. Hillers Regional General Hospital, Maumere

Background: Post-Claim Verification (PCV) is conducted by the Health Social Security Agency (BPJS Kesehatan) to assess the eligibility of claims under the National Health Insurance (JKN) Program. Ineligible claims may result in refunds and affect hospital revenue management. Evidence on PCV findings and hospital revenue flow remains limited. Objective: This study aimed to describe JKN post-claim verification findings, identify administrative factors related to ineligible claims, and assess the Revenue Flow Equation (RFE) and Billing Efficiency Score (BES) at dr. T.C. Hillers Regional General Hospital, Maumere. Methods: A descriptive quantitative case study was conducted using secondary data from the 2025 Post-Claim Verification Results Reports (BAHV-PK) of the Casemix Unit. The population comprised 1,083 outpatient and inpatient claim files, with 292 files selected using the Slovin formula and stratified systematic random sampling. Data were analyzed using frequencies, percentages, BES, and RFE. Results: Of the 1,083 claim files, 588 (54.3%) were eligible and 495 (45.7%) were ineligible. Patient identity and SEP completeness reached 100%, whereas all 119 outpatient referral/control letters were incomplete. Administrative findings included incomplete referral/control letters (119 cases) and inpatient readmissions (10 cases; 5.8%). Internal Medicine had the highest proportion of findings (41.1%). BES ranged from 98.25% to 99.71%, with a mean of 99.22%, while RFE remained positive throughout the measurement period. Conclusion: PCV supports administrative evaluation and JKN claim control. Strengthening internal verification may reduce ineligible claims and improve hospital revenue management.