Purpose: This study aims to analyze strategies for optimizing the financial performance of Manah Shanti Mahottama Hospital, Bangli, Bali, by examining BPJS Health claim effectiveness and internal control robustness.
Research Methodology: This study employed a mixed methods approach using a sequential explanatory design. Quantitative data were obtained from hospital financial reports for 2019–2025 and analyzed to examine the relationships among claim effectiveness, internal control robustness, and financial performance. Qualitative data were collected through in-depth interviews with 12 key informants to identify factors contributing to claim returns and operational challenges.
Results: The findings indicate that effective BPJS Health claim management significantly improves hospital financial performance, while robust internal controls strengthen both claim effectiveness and financial outcomes. Claim returns averaged 8.73% annually and were mainly associated with incomplete medical records, INA-CBGs coding errors, and late claim submissions. These findings highlight the importance of integrated claim management, internal control, and operational improvement.
Conclusions: Strengthening claim management and internal controls is essential for improving hospital financial sustainability. The findings support the development of the OPTIMA strategy as an integrated approach to improving claim processes, information systems, and adaptive management.
Limitations: This study focuses on a single hospital, limiting the generalizability of the findings to other healthcare institutions.
Contributions: This study contributes to hospital financial management literature by proposing the OPTIMA framework, which integrates process optimization, information technology, and adaptive management to strengthen claim effectiveness and financial performance.