REFORMULASI PENGATURAN LAYANAN GAWAT DARURAT PESERTA BADAN PENYELENGGARA JAMINAN SOSIAL (BPJS) KESEHATAN DI RUMAH SAKIT YANG BERKEADILAN

Pasal 19 ayat (2) UU No. 40 Tahun 2004 menegaskan: Jaminan kesehatan diselenggarakan dengan tujuan menjamin agar peserta memperoleh manfaat pemeliharaan kesehatan dan perlindungan dalam memenuhi kebutuhan dasar kesehatan. Pasal 6 ayat (1) Perpres 82/2018 jo. 59/2024 menyatakan: Setiap penduduk Indonesia wajib ikut serta dalam program Jaminan Kesehatan. Serta Pasal 63 ayat (4) menegaskan: dokter penanggung jawab pasien berwenang menetapkan terpenuhinya kriteria gawat darurat. Pasal 47 ayat (1) Permenkes No. 47 Tahun 2018 menetapkan bahwa Badan Penyelenggara Jaminan Sosial (BPJS) menjamin pelayanan kesehatan perorangan, termasuk pelayanan di unit gawat. Praktik di Instalasi Gawat Darurat (IGD) terhadap pasien BPJS menunjukkan kecenderungan mengalami ketidakpastian jaminan pembiayaan, dokter jaga di IGD rumah sakit mengalami dileman untuk penetuan kriteria gawat darurat, usulan klaim kepada pihak BPJS seringkali mengalami penolakan, akibat penafsiran kriteria gawat darurat yang cenderung tidak seragam baik antar dokter di IGD rumah sakit yang berbeda, maupun antar dokter dan verifiktor BPJS.Tujuan penelitian ini: 1). Mengetahui dan menganalisis pengaturan layanan gawat darurat bagi peserta BPJS Kesehatan di rumah sakit saat ini; 2). Mengetahui dan menganalisis layanan gawat darurat bagi peserta BPJS di rumah sakit yang belum berkeadilan; 3). Menemukan reformulasi pengaturan layanan gawat darurat bagi peserta BPJS di rumah sakit yang berkeadilan. Metode penelitian menggunakan yuridis normatif empiris dengan paradigma post-positivisme, Spesifikasi penelitian bersifat perskriptif, sumber data yaitu data sekunder dan data primer, metode pengumpulan data dengan studi dokumen dan wawancara, lokasi penelitian: RSUD K.R.M.T. Wongsonegoro Kota Semarang RSUD Dr. Tengku Mansyur Sumatera Utara RSUD Lasinrang Pinrang Sulawesi Selatan RSU Islam Kota Ternate Maluku Utara merepresentasikan variasi karakteristik geografis pelayanan regional dan tipe kepemilikan, informan penelitian terdiri atas 3 kelompok: 1). dokter jaga IGD. 2). petugas casemix klaim BPJS. 3). pasien peserta BPJS Kesehatan. Metode analisis secara kualitatif, Penyajian data secara naratif kualitatif. Hasil penelitian: (1). Pengaturan layanan gawat darurat bagi peserta BPJS Kesehatan pada saat ini telah diatur dalam UU 17/2023, Perpres 82/2018 jo. 59/2024, dan Permenkes 47/2018, Ketidakseragaman kriteria gawat darurat oleh dokter jaga IGD dalam empat kasus pasien tidak semata disebabkan perbedaan kompetensi klinis, melainkan ketidaksinkronan antara norma hukum, standar klinis, dan mekanisme administratif BPJS. Peraturan Presiden Nomor 82 Tahun 2018 tentang Jaminan Kesehatan memang memberi kewenangan kepada dokter, namun tidak menetapkan kriteria operasional yang seragam. Akibatnya, penentuan status gawat darurat bergantung pada clinical judgment yang subjektif, sehingga menimbulkan variasi interpretasi, ketidakpastian pembiayaan, dan ketidakadilan pelayanan kesehatan. (2). Layanan gawat darurat bagi peserta BPJS di rumah sakit belum berkeadilan karena terjadi disharmoni antara norma hukum, standar medis, dan mekanisme administratif BPJS. Peraturan Presiden Nomor 82 Tahun 2018 tentang Jaminan Kesehatan belum terimplementasi konsisten, sehingga otoritas medis sering dikalahkan verifikasi administratif. Akibatnya, muncul ketidakpastian jaminan, penolakan klaim, keterlambatan layanan, dan pergeseran beban biaya kepada pasien, yang mencerminkan kegagalan perlindungan hukum substantif. (3) Reformulasi layanan gawat darurat BPJS berkeadilan menekankan masalah bukan kekurangan regulasi, melainkan ketidaksinkronan norma dan implementasi, sehingga diperlukan penguatan aspek operasional, integrasi klinis-administratif, supremasi hukum, finalitas klinis, prinsip treat first verify later, standarisasi triase, penjaminan otomatis, dan penghapusan hambatan administratif.
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Article 19 paragraph (2) of Law No. 40 of 2004 states: Health insurance is organized with the aim of ensuring that participants receive health care benefits and protection in meeting basic health needs. Article 6 paragraph (1) of Presidential Decree 82/2018 in conjunction with 59/2024 states: Every Indonesian citizen is required to participate in the Health Insurance program. And Article 63 paragraph (4) states: the doctor in charge of the patient has the authority to determine whether emergency criteria are met. Article 47 paragraph (1) of Minister of Health Regulation No. 47 of 2018 stipulates that the Social Security Administering Body (BPJS) guarantees individual health services, including services in the emergency unit. Practices in the Emergency Room (IGD) for BPJS patients show a tendency to experience uncertainty in financing guarantees, doctors on duty in the hospital ER experience a dilemma in determining emergency criteria, claim proposals to BPJS are often rejected, due to the interpretation of emergency criteria that tend to be inconsistent both between doctors in different hospital ERs, as well as between doctors and BPJS verifiers. The purpose of this study: 1). To find out and analyze the current emergency service arrangements for BPJS Health participants in hospitals; 2). To find out and analyze emergency services for BPJS participants in hospitals that are not yet equitable; 3). To find a reformulation of emergency service arrangements for BPJS participants in hospitals that are equitable. The research method uses empirical normative juridical with a post-positivism paradigm, the research specifications are prescriptive, data sources are secondary data and primary data, data collection methods with document studies and interviews, research locations: KRMT Wongsonegoro Regional General Hospital, Semarang City, Dr. Soetomo General Hospital, Semarang City. Tengku Mansyur North Sumatra Lasinrang Regional General Hospital Pinrang South Sulawesi Islamic General Hospital Ternate City North Maluku represents the variation of geographical characteristics of regional services and ownership types, research informants consist of 3 groups: 1). Emergency Room doctors. 2). BPJS claim casemix officers. 3). BPJS Health participant patients. Qualitative analysis method, qualitative narrative data presentation. Research results: (1). Emergency service arrangements for BPJS Health participants are currently regulated in Law 17/2023, Presidential Decree 82/2018 jo. 59/2024, and Minister of Health Regulation 47/2018, The non-uniformity of emergency criteria by emergency room doctors in four patient cases is not solely due to differences in clinical competence, but rather the lack of synchronization between legal norms, clinical standards, and BPJS administrative mechanisms. Presidential Regulation Number 82 of 2018 concerning Health Insurance does give authority to doctors, but does not establish uniform operational criteria. As a result, the determination of emergency status depends on subjective clinical judgment, resulting in varying interpretations, uncertainty in financing, and unfairness in health services. (2). Emergency services for BPJS participants in hospitals are not yet equitable due to disharmony between legal norms, medical standards, and BPJS administrative mechanisms. Presidential Regulation Number 82 of 2018 concerning Health Insurance has not been implemented consistently, so that medical authorities are often defeated by administrative verification. As a result, there is uncertainty in guarantees, claim rejections, delays in services, and shifting of the cost burden to patients, which reflects the failure of substantive legal protection. (3) Reformulating BPJS emergency services with equity emphasizes that the problem is not a lack of regulation, but rather a lack of synchronization of norms and implementation, so that it is necessary to strengthen operational aspects, clinical-administrative integration, the rule of law, clinical finality, the principle of treat first verify later, standardization of triage, automatic guarantees, and the elimination of administrative barriers.