Abstrak
Latar belakang : Sistem pembiayaan pelayanan kesehatan bagi peserta Jaminan Kesehatan Nasional (JKN) melalui BPJS Kesehatan menggunakan mekanisme tarif paket INA-CBGs, yang menuntut rumah sakit untuk mengelola pelayanan secara efisien tanpa mengurangi mutu pelayanan. Namun dalam praktiknya, rumah sakit sering menghadapi selisih tarif negatif, yaitu kondisi ketika biaya riil pelayanan melebihi tarif klaim yang dibayarkan oleh BPJS Kesehatan. Penelitian ini bertujuan untuk menganalisis penerapan manajemen dalam mengatasi selisih tarif pelayanan rawat inap Pasien Jaminan Kesehatan Nasional di RS Wijaya Kusumah Kuningan dengan menggunakan kerangka Input, Proses, dan Output. Metodologi Penelitian : Penelitian ini merupakan penelitian observasional dengan pendekatan mixed-method, yaitu mengkombinasikan analisis kuantitatif dan kualitatif. Data kuantitatif diperoleh dari dokumen klaim pelayanan rawat inap Pasien Jaminan Kesehatan Nasional periode Januari–Desember 2024, sedangkan data kualitatif dikumpulkan melalui wawancara mendalam dengan informan kunci yang terdiri dari manajemen rumah sakit, tenaga medis, keperawatan, unit casemix, case manager, serta tim kendali mutu dan kendali biaya. Analisis data kuantitatif dilakukan secara deskriptif, sementara data kualitatif dianalisis menggunakan analisis tematik. Hasil Penelitian : Hasil penelitian menunjukkan bahwa dari total 8.514 Surat Eligibilitas Peserta (SEP) rawat inap, sebanyak 2.735 SEP (32%) mengalami selisih tarif negatif dengan total nilai mencapai Rp3.771.224.647. Selisih tarif negatif paling banyak terjadi pada kelas perawatan 3, yang juga merupakan kelas dengan volume pasien tertinggi. Lama hari rawat (Length of Stay/LOS) yang melebihi standar INA-CBGs, variasi pelayanan klinis, keterbatasan penerapan Clinical Pathway , serta keterbatasan jumlah dan peran case manager menjadi faktor utama yang berkontribusi terhadap terjadinya selisih tarif. Dari sisi proses, alur pengajuan klaim telah berjalan sesuai ketentuan, namun masih ditemukan kendala berupa kelengkapan berkas klaim dan perlunya perbaikan dokumen berdasarkan feedback BPJS Kesehatan. Kesimpulan : Penelitian ini menunjukkan bahwa fungsi manajemen dalam pengendalian biaya pelayanan rawat inap di RS Wijaya Kusumah belum berjalan optimal. Diperlukan penguatan kebijakan pengendalian biaya berbasis analisis risiko, optimalisasi peran case manager, penerapan dan evaluasi Clinical Pathway secara konsisten, serta monitoring selisih tarif secara berkelanjutan agar selisih tarif negatif dapat ditekan tanpa menurunkan mutu pelayanan kesehatan.
Background: The healthcare financing system for participants of the National Health Insurance (JKN) in Indonesia, administered by BPJS Kesehatan, applies a case-based payment system using INA-CBGs tariffs. This system requires hospitals to deliver healthcare services efficiently while maintaining service quality. However, in practice, hospitals frequently experience negative tariff differences, where the actual cost of inpatient services exceeds the reimbursement paid by BPJS Kesehatan. This study aims to analyze hospital management practices in addressing cost discrepancies in inpatient services for BPJS Kesehatan patients at Wijaya Kusumah Hospital, Kuningan, using the Input–Process–Output framework. Research Methodology: This study employed an observational design with a mixed-method approach, integrating quantitative and qualitative analyses. Quantitative data were obtained from inpatient claim documents of BPJS Kesehatan patients for the period January–December 2024, while qualitative data were collected through in-depth interviews with key informants, including hospital management, medical and nursing staff, the casemix unit, case managers, and the quality and cost control team. Quantitative data were analyzed descriptively, and qualitative data were examined using thematic analysis. Research Results: The results showed that out of 8,514 inpatient Eligibility Letters (SEP), 2,735 cases (32%) experienced negative tariff differences, with a total deficit of IDR 3,771,224,647. The largest proportion of negative tariff differences occurred in Class 3 inpatient services, which also had the highest patient volume. Prolonged length of stay beyond INA-CBGs standards, variations in clinical practice, limited implementation of Clinical Pathway s, and insufficient case manager capacity were identified as major contributing factors to cost discrepancies. From the process perspective, although the claim submission workflow followed BPJS Kesehatan regulations, challenges remained related to claim document completeness and revisions required following BPJS Kesehatan feedback. Conclusion: In conclusion, hospital management functions in controlling inpatient service costs at Wijaya Kusumah Hospital have not yet been fully optimized. Strengthening cost control policies based on risk analysis, optimizing the role of case managers, consistently implementing and evaluating Clinical Pathway s, and conducting routine monitoring of cost discrepancies are essential strategies to reduce negative tariff differences while maintaining the quality of healthcare services.