SURABAYA, JurnalPost.com – Healthcare services today are inseparable from the existence of BPJS Kesehatan, a public legal entity established to manage the national health insurance program for the people of Indonesia.
In 2004, the government enacted Law Number 40 of 2004 concerning the National Social Security System (SJSN) as the foundation for the social security system in Indonesia. BPJS Kesehatan began operations on January 1, 2014, to implement Law Number 24 of 2011 concerning the Social Security Organizing Agency.
The government manages the National Health Insurance (JKN) as a manifestation of the state's responsibility to ensure access to healthcare services for the public.
Through the JKN system managed by BPJS Kesehatan, the public is expected to receive healthcare services in accordance with applicable regulations without having to bear the full burden of medical costs independently.
The presence of JKN is a significant step toward realizing social justice in the health sector and expanding access to decent healthcare services for the community.
However, the implementation of JKN does not automatically guarantee all healthcare services. Article 52 paragraph (1) of Presidential Regulation Number 82 of 2018 concerning Health Insurance, as amended several times, most recently by Presidential Regulation Number 59 of 2024, regulates 21 categories of healthcare services that are not covered by the JKN program.
Some of these include services for aesthetic purposes, infertility treatments, orthodontic care, health issues resulting from intentional self-harm, and services already covered by other programs in accordance with applicable regulations.
These provisions indicate that health service coverage through JKN must consider the type of service, the underlying condition, and the applicable coverage regulations.
Such coverage limitations can create issues in healthcare practice, including when patients arrive at a hospital's emergency department (ER) and the required services are declared not covered by BPJS Kesehatan.
This situation becomes more complex when decisions regarding coverage are perceived as decisions made by the attending physician. In reality, clinical decisions regarding the need for medical action must be distinguished from administrative decisions regarding financing coverage.
On one hand, medical personnel are obligated to provide services according to medical needs, professional standards, and applicable legal provisions. On the other hand, there are JKN benefit provisions and coverage mechanisms that must be adhered to by the relevant parties.
This issue raises the question: when a healthcare service is not covered by BPJS Kesehatan, to what extent is the physician responsible to the patient?
Separating Medical Responsibility and JKN Coverage
As medical personnel, physicians have a professional responsibility to perform examinations, establish diagnoses according to their competence, determine the need for medical action, and provide services based on professional standards, professional service standards, standard operating procedures, and professional ethics while considering the patient's health needs.
However, financing coverage through JKN is subject to the applicable benefit provisions, administrative requirements, service procedures, and claim mechanisms.
Therefore, a decision that a service is not covered by BPJS Kesehatan does not automatically indicate professional misconduct by the physician.
The assessment of legal responsibility must consider the authority of each party, the reasons for the denial of coverage, and any actions or negligence that occurred during the service.
Law Number 40 of 2004 concerning the National Social Security System and Law Number 24 of 2011 concerning the Social Security Organizing Agency serve as the basis for health insurance implementation in Indonesia.
These provisions must be read in conjunction with Presidential Regulation Number 82 of 2018 concerning Health Insurance and its amendments to understand the scope of benefits and exclusions of JKN coverage.
Thus, when a coverage denial occurs, it is necessary to investigate the reasons for the denial, the legal basis used, and the party authorized to make the decision.
Legal responsibility should not be placed on the physician simply because they are the party dealing directly with the patient.
Nevertheless, physicians as medical personnel remain legally responsible for the professional services provided.
Article 274 of Law Number 17 of 2023 concerning Health regulates the obligations of medical and health personnel to practice in accordance with professional standards, professional service standards, operational procedures, professional ethics, and the patient's health needs.
Meanwhile, Article 276 regulates patient rights, including obtaining information about their health and adequate explanations regarding the services received.
These provisions confirm that the responsibility of health personnel must be assessed based on their professional actions.
If services have been provided according to standards, a physician cannot be automatically blamed simply because the financing is not covered by BPJS Kesehatan.
Conversely, if there is a breach of professional obligations, accountability must be assessed based on the facts and applicable legal provisions.
Obligations for Patient Handling in the Emergency Department
This issue becomes increasingly important in emergency department (ER) services. In emergency situations, patient handling must be based on clinical conditions and medical needs.
Article 174 of Law Number 17 of 2023 concerning Health regulates the obligations of healthcare facilities in emergency situations.
Meanwhile, Article 275 regulates the obligations of medical and health personnel practicing in healthcare facilities to provide first aid to patients in emergency and/or disaster situations.
Therefore, administrative and coverage issues must not override the obligation to handle emergencies in accordance with legal provisions.
However, the obligation to provide emergency handling does not automatically mean that all actions, medications, and examinations are covered by JKN.
The aspects of medical service obligations and financing coverage need to be analyzed separately in accordance with applicable regulations.
In such situations, the physician still plays a role in providing explanations regarding the medical condition, indications for action, benefits, and risks of the service according to their authority.
Information regarding membership status, benefit provisions, administrative reasons for denial, and claim mechanisms must be supported by accurate information from the authorized party.
This division of roles is necessary so that patients receive clear information and physicians are not burdened with responsibility for decisions that fall outside their authority.
Patient and Physician Protection
The protection of patients and physicians as medical personnel in the implementation of JKN should not be viewed as two conflicting interests.
Patients have the right to obtain clear information regarding services and their coverage status, while health personnel have the right to practice their profession according to their competence and authority.
In this regard, healthcare facilities need to ensure coordination between medical personnel, the administrative unit, claim managers, and BPJS Kesehatan.
If a service is declared not covered, the patient needs to receive an explanation regarding the reasons for the denial, the legal basis used, and the available complaint or review mechanisms.
Transparency of information is necessary to prevent misunderstandings between patients and health personnel.
A physician's responsibility must be limited to professional actions according to their competence and applicable standards, while coverage decisions are the responsibility of the party authorized to set them.
If allegations of professional misconduct arise, the physician's accountability must be assessed objectively based on the facts and applicable legal provisions.
When a healthcare service is not covered by BPJS Kesehatan, the issue cannot be resolved simply by finding someone to blame.
It is necessary to investigate the reasons for the denial, the authority of the decision-maker, and the legal obligations of each party.
Thus, problem-solving should not only focus on determining who is at fault, but also on the clarity of the basis for coverage decisions and the division of responsibilities.
The success of JKN is not only determined by the breadth of membership coverage, but also by the certainty of coverage, transparency of information, and clarity in the division of responsibilities.
Physicians do have legal responsibilities in practicing their profession, but that responsibility cannot be automatically extended to cover all JKN financing issues.
A fair JKN system must be able to protect patient rights while providing legal certainty for physicians as medical personnel.
Therefore, when services are not covered by BPJS Kesehatan, what needs to be clarified is not only the coverage status, but also who is authorized to make the decision and who is legally responsible for that decision.
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