Jasran Asya (1)
General Background: National health insurance programs create complex legal relationships between healthcare providers and purchasing institutions, particularly regarding reimbursement and accountability. Specific Background: Private hospitals operating under Indonesia's National Health Insurance program face contractual and regulatory challenges, illustrated by two disputes involving RSIA Tiara and BPJS Kesehatan concerning retrospective claim deductions and cesarean section reimbursement audits. Knowledge Gap: Existing regulatory arrangements leave questions regarding contractual authority, administrative accountability, medical assessment standards, and dispute resolution procedures. Aims: This study examines hospital business challenges and formulates legal recommendations using normative juridical research supported by statutory, case, and conceptual approaches grounded in Wolfgang Friedmann's functional critical legal theory. Results: Five interconnected challenges were identified: asymmetric hybrid legal relationships, regulatory uncertainty, potential escalation of administrative disagreements into fraud allegations, inadequate dispute resolution mechanisms, and tensions between administrative and clinical assessments. Retrospective deductions and contemporary reimbursement audits require distinct legal evaluations. Novelty: The study applies Friedmann's functional legal perspective to distinguish contractual, regulatory, and clinical dimensions of hospital reimbursement disputes within a single analytical framework. Implications: Hospitals should strengthen contractual safeguards and clinical documentation, while regulators should establish transparent audit procedures, independent dispute resolution mechanisms, and appropriate clinical review standards to support legal certainty and institutional accountability.
Highlights:
Hybrid contractual arrangements create asymmetric authority between providers and purchasing institutions.
Retrospective deductions and surgical reimbursement audits raise distinct questions of legality.
Five interconnected challenges demonstrate the need for independent review and transparent procedures.
Keywords: JKN, BPJS Kesehatan, Hospitals, Claim Disputes, Friedmann’s Legal Theory
[1] S. Wusono, J. Hendrartini, and D. H. Sulistyo, “Analisis tarif pelayanan poli penyakit dalam di rumah sakit umum daerah dalam era Jaminan Kesehatan Nasional,” Jurnal Manajemen Pelayanan Kesehatan (The Indonesian Journal of Health Service Management), vol. 23, no. 3, pp. 95–100, Mar. 2022, doi: 10.22146/jmpk.v23i03.4247.
[2] I. M. Hasibuan, Pakam, F. Kasim, Pakam, and S. M. B. Bangun, “Perbandingan biaya rumah sakit dengan paket INA-CBGs pada pembayaran klaim sectio caesarea pasien BPJS di RSU Indah Kota Bagan Batu Riau tahun 2025,” Journal of Healthcare Technology and Medicine, vol. 11, no. 1, 2025, doi: 10.33143/jhtm.v11i1.4808.
[3] W. Friedmann, Legal Theory, 4th ed. London, UK: Stevens & Sons Ltd., 1960.
[4] R. Zubaedah, E. Nurlailasari, and N. Apriningrum, “Perjanjian kerjasama pelayanan Jaminan Kesehatan Nasional di Kabupaten Karawang,” Jurnal Ilmiah Hukum DE'JURE: Kajian Ilmiah Hukum, vol. 4, no. 1, pp. 135–149, 2019, doi: 10.35706/dejure.v4i1.1866.
[5] M. Irayadi, “Legal protection for Social Security Administering Body Health participants,” Awang Long Law Review, vol. 6, no. 2, May 2024, doi: 10.56301/awl.v6i2.1308.
[6] I. N. D. Wiasa and I. N. Budiana, “Implementasi perlindungan konsumen peserta BPJS dalam pelayanan kesehatan di RSUP Sanglah Denpasar,” Jurnal Analisis Hukum, vol. 2, no. 2, pp. 181–193, 2019, doi: 10.38043/jah.v2i2.2206.
[7] A. D. Fitria, F. Salwa, K. Khairani, S. R. Ujung, and S. H. Purba, “Studi literature perlindungan hukum bagi pasien BPJS dalam pelayanan kesehatan di rumah sakit,” Indonesian Journal of Health Science, vol. 4, no. 3, pp. 246–255, Jun. 2024, doi: 10.54957/ijhs.v4i3.923.
[8] Haridiva, “iDRG: Sistem baru pembiayaan JKN dan tantangan mitigasi risiko keuangan rumah sakit,” Legawa, Jun. 2, 2026. [Online]. Available: https://legawa.com/2026/06/02/idrg-sistem-baru-pembiayaan-jkn-dan-tantangan-mitigasi-risiko-keuangan-rumah-sakit/
[9] E. S. Maulida and A. Djunawan, “Analisis penyebab pending claim berkas BPJS Kesehatan pelayanan rawat inap Rumah Sakit Universitas Airlangga,” Media Kesehatan Masyarakat Indonesia, vol. 21, no. 6, pp. 374–379, Dec. 2022, doi: 10.14710/mkmi.21.6.374-379.
[10] A. A. U. Amri and A. Nurwahyuni, “Analisis klaim pending, verifikasi dan audit pascaklaim Jaminan Kesehatan Nasional,” Jurnal Ekonomi Kesehatan Indonesia, vol. 9, no. 2, Dec. 2024, doi: 10.7454/eki.v9i2.1132.
[11] J. N. Rizki, A. A. Sari, Y. Yektiningtyastuti, and E. Suprihatin, “Penyebab pengembalian klaim BPJS rawat inap triwulan 1 tahun 2024 di RSI Sultan Agung Semarang,” J-REMI: Jurnal Rekam Medik dan Informasi Kesehatan, vol. 6, no. 2, pp. 156–167, Mar. 2025, doi: 10.25047/j-remi.v6i2.5853.
[12] R. Amran, “Prosedur BPJS dan klaim BPJS oleh rumah sakit,” Health and Medical Journal, vol. 5, no. 2, pp. 147–154, May 2023, doi: 10.33854/heme.v5i2.1338.
[13] T. S. Hartati, “Pencegahan kecurangan (fraud) dalam pelaksanaan program jaminan kesehatan pada Sistem Jaminan Sosial Kesehatan (SJSN) (Studi di Rumah Sakit Umum Daerah Menggala Tulang Bawang),” Fiat Justisia: Jurnal Ilmu Hukum, vol. 10, no. 4, p. 715, May 2017, doi: 10.25041/fiatjustisia.v10no4.808.
[14] S. Sulaiman, F. S. Margono, B. Ahoen, and A. Hutauruk, “Tinjauan terhadap sengketa klaim pembayaran peserta Jaminan Kesehatan Nasional antara Badan Penyelenggara Jaminan Sosial Kesehatan dan Rumah Sakit Graha Medika Kenari Kabupaten Bogor,” College Studies Journal, vol. 9, no. 1, pp. 365–376, Jun. 2026, doi: 10.56301/csj.v9i1.2381.
[15] H. Riswanti, T. Tohir, and A. Lucyanti, “Evaluasi dan penguatan sanksi hukum dalam penanggulangan kecurangan (fraud) pada sistem pembayaran Jaminan Kesehatan Nasional (JKN) di Indonesia,” Jurnal Riset Rumpun Ilmu Sosial, Politik dan Humaniora, vol. 5, no. 2, pp. 249–263, 2026, doi: 10.55606/jurrish.v5i2.7257.
PRIN
[16] L. Z. Camellia and A. W. Kartika, “Aspek keperdataan dalam upaya penyelesaian sengketa medis antara pasien dengan tenaga medis berdasarkan Undang-Undang Kesehatan,” Jurnal Hukum & Pembangunan, vol. 54, no. 3, Sep. 2024, doi: 10.21143/jhp.vol54.no3.1647.
[17] S. P. Ngura, “Penyelesaian sengketa pelayanan kesehatan penerima layanan kesehatan perspektif hukum acara perdata,” ADHAPER: Jurnal Hukum Acara Perdata, vol. 10, no. 2, pp. 110–127, Dec. 2024, doi: 10.36913/adhaper.v10i02.60.
ADHAPER: Jurnal Hukum Acara Perdata+1
[18] A. Hayati, S. C. Budi, and I. A. Dani, “Analysis of differences between hospital rates and INA-CBG’s claim of sectio caesarea,” Procedia of Engineering and Life Science, vol. 6, pp. 18–23, Nov. 2024, doi: 10.21070/pels.v6i1.1924.
[19] A. Oktapiyani, E. Fransisca, and A. Rois, “Faktor-faktor yang berhubungan dengan proses klaim BPJS Kesehatan pada pasien sectio caesaria di Rumah Sakit Umum Daerah Pakuhaji,” Quantum Wellness: Jurnal Ilmu Kesehatan, vol. 1, no. 3, pp. 106–118, Aug. 2024, doi: 10.62383/quwell.v1i3.741.
[20] C. Rahmatiqa, I. N. Sulrieni, and A. Novita Sary, “Kelengkapan berkas rekam medis dan klaim BPJS di RSUD M. Zein Painan,” Jurnal Kesehatan Medika Saintika, vol. 11, no. 1, p. 11, Jun. 2020, doi: 10.30633/jkms.v11i1.514.