AN INTEGRATED FRAMEWORK FOR HEALTH CLAIM CLASSIFICATION AND HOSPITAL FINANCIAL VIABILITY.

Abstract

This study examines the integration of Decision Tree Pruning and Performance Prism to improve the accuracy of BPJS Kesehatan (Social Security Agency for Health) claim classification and its impact on hospital financial viability. As healthcare facilities in Indonesia continue to grow, accurate financial evaluation is crucial, as BPJS claims represent a vital source of revenue. Using a mixed-methods approach, the Decision Tree Pruning model achieved 99.9% accuracy and identified document completeness as the most dominant claim factor. The implementation of this model was proven to increase hospital revenue, with net cash flow rising from IDR 5.79 billion to IDR 6.28 billion. An investment feasibility analysis revealed a 60.7% increase in Net Present Value (NPV) and an 8-month acceleration in the Payback Period. Furthermore, an evaluation using the Performance Prism confirmed enhanced stakeholder satisfaction and service quality. This study demonstrates that integrating these two methods effectively enhances both financial performance and the efficiency of BPJS Kesehatan claim management.