Mentoring for the Integration of Quality Management and Financial Control at PKU Sekapuk Hospital

The financial dependence of regional private hospitals on claims from the Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS Kesehatan) demands a robust daily revenue cycle. Internal coordination at PKU Sekapuk Hospital in Lamongan is reactive, limited to post-claim rejection issues, without integrated guidance documents, leading to high claim dispute rates and cost leakage. Community Empowerment Program (CEP) aims to secure the hospital’s cash flow through synchronized quality control and cost control. The method used is a multidisciplinary reconciliation workshop and collaborative medical record audit, bringing together the Medical Committee (Doctors) and the Administrative Team (Coders/Finance) based on the BPJS Balanced Hospital Operating Model Framework. This CEP successfully formulated a formal Clinical Pathway Blueprint document for the 10 diagnoses with the highest case volume. The implementation results have proven effective in controlling unnecessary variations in medical operational costs through standardized drug formularies and increasing the net claim acceptance rate above 95%. This document serves as the final pillar of a holistic solution to boost the hospital’s financial competitiveness.