Menyamakan Persepsi Tentang “EPISODE” Dalam Pelayanan Peserta JKN Oleh BPJS Kesehatan

Dalam pelayanan terhadap peserta JKN oleh BPJS Kesehatan di FKRTL atau Rumah Sakit, dikenal istilah EPISODE. Namun ternyata dalam praktek di lapangan masih ditemukan beberapa “bias” pemahanan tentang Episode ini. Sebuah RS mungkin masih menerjemahkan secara berbeda dengan RS lain, bahkan (maaf) beberapa Kantor Cabang BPJS juga masih ada yang mempraktekan agak berbeda dengan cabang lain, sehingga mengeluarkan beberapa aturan atau kebijakan lokal kepada RS. Bagi masyarakat dan RS tentu saja ini cukup membingungkan karena adanya pemahaman yang berbeda-beda. Bagi RS, Episode ini penting karena menyangkut ke jumlah berkas atau jumlah kunjungan yang akan diklaim ke BPJS sehingga terkait dengan pembayaran oleh BPJS kepada RS. Perlu dipahami bahwa Episode ini sangat terkait dengan Surat Eligibilitas Peserta (SEP) atau semacam Surat Jaminan Pelayanan (SJP) dulu saat era sebelum JKN.

DEFINISI EPISODE

Berdasarkan Permenkes Nomor 27 Tahun 2014 tentang Petunjuk Teknis Sistem INA CBG,EPISODE adalah jangka waktu perawatan pasien mulai dari pasien masuk sampai pasien keluar rumah sakit, termasuk konsultasi dan pemeriksaan dokter, pemeriksaan penunjang maupun pemeriksaan lainnya. Pada sistem INA-CBG, hanya ada 2 episode yaitu episode rawat jalan dan rawat inap.

Bagaimana dengan kasus emergency ? Kasus Emergency atau gawat darurat bisa dimasukkan dalam episode rawat jalan sebagai Rawat Jalan Tingkat Lanjut (RJTL) jika pasien pulang setelah mendapat pelayanan IGD ataupun bisa dimasukkan dalam episode rawat inap sebagai Rawat Inap Tingkat Lanjut (RITL) jika pasien secara medis atas intruksi dokter harus dilakukan rawat inap. Untuk episode rawat inap hampir tidak ada permasalahan pada penafsiran karena memang sangat mudah dinilai satu episode rawat inap yaitu dari mulai pasien masuk ruang rawatan sampai pulang. Namun untuk episode rawat jalan yang sangat banyak varian nya di RS, ternyata masih berbeda-beda dalam menyikapi dan mendefinisikannya.

Episode Rawat Jalan

Satu episode rawat jalan adalah satu rangkaian pertemuan konsultasi antara pasien dan dokter serta pemeriksaan penunjang sesuai indikasi medis dan obat yang diberikan padahari pelayanan yang sama. Apabila pemeriksaaan penunjang tidak dapat dilakukan pada hari yang sama maka tidak dihitung sebagai episode baru. Nah tentu saja kalau dibaca sampai disini saja, maka saya yakin semua akan bergejolak, manajemen RS akan protes dan dokter pasti protes karena terkait pembayaran jasa pelayanan juga.

Namun coba dibaca dan dipahami pada ketentuan berikutnya yang berbunyi Pasien yang MEMBAWA HASIL pada HARI PELAYANAN YANG BERBEDA yang dilanjutkan dengan KONSULTASI dan pemeriksaan penunjang lain sesuai indikasi medis, dianggap sebagai EPISODE BARU.”

Mari coba kita buatkan sebuah ilustarasi :

Pasien atas nama Ny. A usia 53 tahun dengan keluhan dan gejala yang mengarah ke DM Type II dan dicurigai adanya Bronchopneumonia datang berkunjung ke Klinik Penyakit Dalam sebuah RS.

— Kunjungan pertama Ny. A ke klinik Penyakit Dalam dilakukan pada Hari Senin, 9 Maret 2015. Pada hari ini dilakukan pemeriksaan oleh dokter spesialis penyakit dalam kemudian diberikan intruksi pemeriksaan laboratorium kimia darah dan rontgen dada. Pasien BELUMdiberi obat-obatan oleh dokter karena diagnosa pasti belum ditegakkan menunggu hasil pemeriksaan penunjang. Pada hari ini pasien sudah mendapatkan 1 SEP (Surat Eligibilitas Peserta) dari BPJS Kesehatan karena pasien melakukan registrasi di bagian pendaftaran pasien Rawat Jalan.

 

— Kunjungan kedua Ny. A ke RS dilakukan pada Hari Selasa, 10 Maret 2015 dan langsung menuju ke Laboratorium serta Radilogi TANPA harus registrasi lagi dan TANPA adanya SEP lagi. Setelah selesai pemeriksaan, kemudian pasien pulang ke rumah dan diintruksikan untuk mengambil hasil nya pada hari berikutnya yaitu Hari Rabu tanggal 11 Maret 2015. Satu rangkaian ini SUDAH BISA disebut sebagai SATU EPISODE PENUH.

 

— Kunjungan Ketiga Ny. A dilakukan pada Hari Rabu, 11 Maret 2015 dan langsung menuju ke laboratorium dan radiologi untuk mengambil hasil-hasil pemeriksaan yang sudah dilakukan pada hari sebelumnya. Setelah itu Ny. A menuju ruang registrasi untuk mendaftarkan sebagai pasien rawat jalan dan mendapatkan SEP BARU lagi selain SEP yang dia dapatkan pada hari senin. Ny. A kemudian membawa hasil-hasil pemeriksaan tadi ke klinik penyakit dalam dan diserahkan ke dokter untuk dilihat lalu dokter menetapkan diagnosa pasti dan memberikan RESEP obat-obatan yang harus dikonsumsi disertai beberapa saran/nasihat termasuk juga perlu tidaknya kontrol ulang. Pasien kemudian menuju IFRS untuk mengambil obat dan pulang. Nah ini disebut SATU EPISODE PENUH juga.

Jadi selama 3 hari atau 3 kali kunjungan ke RS, pasien mendapatkan DUA EPISODE PENUH dan mendapatkan DUA SEP. Artinya RS dapat melakukan klaim ke BPJS untuk pasien ini sebagai DUA KALI kunjungan.

Jikalau mau di ilustrasikan ke dalam nominal pembayaran, dipersilahkan bagi yang ingin mencoba mengilustrasikan ke dalam tarif paket INA CBG. Saya tidak melakukan ilustrasi ke tarif karena tentu saja harus membandingkan dengan tarif RS (real cost) yang sangat bervariasi, juga perbedaan kelas RS yang mempengaruhi kepada besaran tarif INA CBG. Di sini saya hanya berfokus pada JUMLAH EPISODE dan JUMLAH SEP yang tentu sangat berpengaruh terhadap jumlah klaim ke BPJS.

 

Bagaimana jika pasien Ny. A tersebut dikonsultasikan ke klinik lain (misal ke klinik Neuro atau Bedah atau klinik Pulmo) ?

Berdasarkan ketentuan maka berlaku bahwa pasien yang datang ke rumah sakit mendapatkan pelayanan rawat jalan pada satu atau lebih klinik spesialis pada HARI YANG SAMA, terdiri dari satu atau lebih diagnosis, dimana DIAGNOSIS satu dengan yang lain saling BERHUBUNGAN atau TIDAK BERHUBUNGAN, dihitung sebagai SATU EPISODE.

Nah untuk kasus seperti ini, maka saya memiliki 2 catatan yaitu :

  1. a). Perlu dilakukan evaluasi terhadap aturan ini untuk kasus diagnosa yang TIDAK BERHUBUNGAN, menurut hemat saya meskipun dilakukan pada hari yang sama namun mestinya menjadi EPISODE BARU dengan 1 SEP tersendiri. Kecuali jika memang diagnosanya masih saling berhubungan maka saya sepakat untuk dianggap SATU EPISODE.
  2. b). Jika memang “terpaksa” harus dilakukan konsultasi internak untuk diagnosa YANG BERHUBUNGAN, mungkin bisa dipertimbangkan untuk dilakukan konsultasi internal pada hari yang berbeda. Misalkan dokter penyakit dalam pada saat kunjungan pertama, selain memberi intruksi untuk pemeriksaan penunjang juga menuliskan surat rujukan internal untuk dibawa oleh pasien pada kunjungan kedua. Jadi pada kunjungan kedua, setelah pasien diperiksa laboratorium dan radiologi maka pasien mendaftarkan (registrasi) ke klinik yang dituju sesuai rujukan dokter penyakit dalam. Sehingga pasien mendapatkan SEP BARU lagi dan dianggap SATU EPISODE tersendiri diluar rangkaian episode di klinik penyakit dalam. Sehingga dalam kasus ini, Ny. A bisa mendapatkan minimal 3 SEP.

Namun secara pribadi saya lebih mendorong ke arah REVISI terkait aturan ini. Karena meskipun dilakukan langkah seperti poin nomor 2 diatas, namun masih berpotensi untuk ditolak oleh verifikator BPJS atau minimal membutuhkan argumentasi dan sedikit “debat” memberikan penjelasan kepada verifikator BPJS. Hal ini karena RS dapat dianggap “mengakali” aturan dengan “memecah-mecah” pelayanan atau dikenal dengan istilah “UNBUNDLING“. Sehingga akan jauh lebih baik jika mengajukan evaluasi dan revisi terhadap aturan ini kepada Kemenkes selaku regulator.

Sebagai tambahan terdapat dua kondisi khusus yaitu :

a). Untuk pemeriksaan penunjang canggih dirawat jalan (seperti MRI dan CT Scan) TIDAKmenjadi episode baru karena termasuk dalam special CMG yaitu SPECIAL INVESTIGATION.

b). Pasien datang kembali ke rumah sakit dalam KEADAAN DARURATpada hari pelayanan yang SAMA, maka dianggap sebagai EPISODE BARU.

Pertanyaannya, apakah di lapangan se”simple” atau se”sederahana” seperti yang diilustrasikan di atas ?? Jawabannya bisa iya bisa tidak. Sangat banyak varian di lapangan, terkait kondisi, fasilitas dan sisdur sebuah RS. Sehingga diperlukan sebuah prosedur tetap (SOP) dan alur pelayanan selain Standar Pelayanan Medis atau Protokol Terapi yang ditetapkan oleh direktur RS.

Beberapa informasi yang diterima terkait episode rawat jalan, diantaranya :

  1. Dalam seminggu tidak boleh ada lebih dari 2 kali kunjungan.
  2. Pemeriksaan penunjang harus dilaksanakan pada hari yang sama.
  3. Konsultasi internal harus dilakukan pada hari yang sama.

Maka jawaban saya cukup mengatakan bahwa jika semua Kantor Cabang BPJS menginduk pada peraturan dan ketentuan yang sama, yaitu Permenkes, SE Menkes, Perdir BPJS, SE Direktur Pelayanan BPJS maka semua informasi tadi TIDAK BENAR karena memang tidak sesuai dengan ketentuan dan peraturan yang berlaku. Apabila ada edaran BPJS setempat yang bertentangan dengan aturan-aturan tersebut maka bisa dipertanyakan dan digugat ke Kantor Cabang BPJS karena dalam hukum berlaku azas : LEX SUPERIOR DEROGAT LEGI INFERIOR, artinya peraturan yang lebih tinggi mengesampingkan aturan yang lebih rendah dan berlaku asas hierarki.

 

Episode Rawat Inap

Episode rawat Inap adalah satu rangkaian pelayanan jika pasien mendapatkan perawatan > 6 JAM di rumah sakit ATAU jika pasien TELAH mendapatkan fasilitas rawat inap (bangsal/ruang rawat inap dan/atau ruang perawatan intensif) walaupun lama perawatanKURANG DARI 6 JAM, dan secara ADMINISTRASI telah menjadi pasien rawat inap.

Pasien yang masuk ke rawat inap sebagai kelanjutan dari proses perawatan di rawat jalan atau gawat darurat, maka kasus tersebut termasuk satu episode rawat inap, dimana pelayanan yang telah dilakukan di rawat jalan atau gawat darurat sudah termasuk didalamnya.

Timbul pertanyaan menarik, bagaimana jika pasien di IGD dan memerlukan rawat inap namun karena keterbatasan fasilitas maka harus dirujuk ke RS lain padahal di IGD BELUM sampai 6 Jam ? Menurut hemat saya, mencermati kalimat “………ATAU jika pasien TELAHmendapatkan fasilitas rawat inap (bangsal/ruang rawat inap dan/atau ruang perawatan intensif) walaupun lama perawatan KURANG DARI 6 JAM, dan secara ADMINISTRASItelah menjadi pasien rawat inap” maka meskipun pasien di IGD masih kurang dari 6 jam tapi secara ADMINISTRASI sudah diregistrasikan sebagai pasien rawat inap maka tetap bisa diklaim sebagai Rawat Inap Tingkat Lanjut (RITL). Intinya adalah jika secara administrasisudah didaftarkan (registrasi) rawat inap meskipun baru 1 jam namun ternyata harus dirujuk maka tetap bisa diklaim sebagai rawat inap dan penjelasannya sangat bisa dipertanggungjawabkan manakala ada pertanyaan dari verifikator BPJS.

Episode Khusus

Dulu saat era ASKES, ada ketentuan klaim untuk pelayanan Fisioterapi atau Rehabilitasi Medik bisa diajukan SETELAH minimal pasien mendapatkan 3 (TIGA) kali pelayanan di Instalasi Rehabilitasi Medik dan Kedokteran Fisik. Ketentuan ini menimbulkan pertentangan dari rumah sakit, saya juga dulu bersuara cukup keras kepada PT. ASKES karena kenyataan di lapangan banyak pasien yang BELUM 3 kali kunjungan tapi sudah tidak berkunjung lagi karena berbagai sebab, ada yang karena merasa sudah sembuh, ada yang meninggal dunia, ada yang pindah RS dan masih banyak lagi faktor penyebabnya. Sehingga RS tidak bisa mengajukan klaim pelayanan fisioterapi ke PT. ASKES dan SJP banyak yang numpuk tidak bisa “dijadikan” uang.

Begitu juga dengan pelayanan perawatan gigi yang bersifat serial dan harus dilakukan dalam serangkaian waktu yang lebih dari satu hari. Dulu hanya boleh diklaimkan dalam satu SJP setelah 1 rangkaian pelayanan perawatan gigi selesai, sehingga menimbulkan protes dari para sejawat dokter gigi dan juga manajemen RS.

Belajar dari pengalaman tersebut, maka dalam pelayanan era JKN ini sudah diperbaiki dan tidak lagi menganut sistem klaim tunggal untuk beberapa kali kunjungan atau pelayanan. Ketentuan tersebut sebagaimana tercantum dalam Permenkes 27 Tahun 2014 yang berbunyi : “Dalam hal pelayanan berupa prosedur yang berkelanjutan di pelayanan rawat jalan seperti radioterapi, kemoterapi, rehabilitasi medik dan pelayanan gigi, episode yang berlaku adalah PER SATU KALI KUNJUNGAN.”

Jadi sangat jelas bahwa pelayanan yang bersifat serial atau berkelanjutan tidak perlu menunggu sekian kali kunjungan atau pelayanan baru bisa diklaim. Namun berlaku aturan bahwa SETIAP KALI kunjungan maka akan TERBIT 1 SEP sehingga bisa diklaimkan. Ini sebuah perubahan besar yang sangat positif bagi masyarakat di era JKN.

PENUTUP 

Berdasarkan paparan tersebut diatas, khusus untuk pelayanan Rawat Jalan saya tidak melakukan justifikasi bahwa RS akan “untung” atau “rugi” memberikan pelayanan peserta JKN di Rawat Jalan, karena persoalan “untung” dan “rugi” itu bersifat variatif dan relatif yang memerlukan perbandingan dengan tarif RS yang bersangkutan. Yang perlu dikaji lagi apakah tarif RS sudah merupakan tarif yang sebenarnya ? Sudah sesuai dengan “real unit cost” ? Jangan-jangan kita sudah merasa “untung” padahal tarif RS kita belum sesuai dengan biaya faktual saat ini. Terutama di RS milik pemerintah, unit cost hanya menjadi salah satu bahan pertimbangan dalam penentuan tarif karena adanya proses akhir yang disebut “kebijakan tarif” atau “Price Policy” yang sangat mungkin dipengaruhi oleh faktor-faktor eksternal (top eksekutif, legislatif) yang bersifat politis. Pun demikian ketika merasa “rugi”, sangat mungkin dikarenakan tarif RS terlalu tinggi, mungkin ada over-treatment atau over-proceduresehingga tarif RS menjadi tinggi.

Pemikiran yang lain adalah ketika kita melihat case by case di rawat jalan, kita melihat kasus per kasus di rawat jalan maka sangat mungkin kita memang menemukan fakta bahwa pembayaran klaim BPJS DIBAWAH tarif RS, namun rasanya tidak fair juga jika kita “MENYEMBUNYIKAN” kasus-kasus dimana pembayaran klaim BPJS MELAMPAUI tarif RS. Yang paling objektive adalah dengan melihat pendapatan operasional rumah sakit secara total (gross/bruto income) berdasarkan klaim pembayaran BPJS lalu kemudian disandingkan dengan total pendapatan jika dihitung dengan tarif RS. Kenapa ? karena mekanisme subsidi silang (cross-subsidy) itu memang sangat mungkin terjadi. Apabila hasil comparasi tersebut ternyata pendapatan dari klaim BPJS lebih rendah dari jika dihitung dengan tarif RS, maka berarti tidak terjadi subsidi silang. RS harus segera menganalisa, melakukan Utilitazion Review (UR), membentuk tim pengendali pelayanan JKN internal RS dan mungkin melakukan evaluasi terhadap tarif RS. Ini tentu saja diluar kesimpulan general bahwasanya secara aktual tarif INA CBG saat ini memang masih dirasakan terlalu rendah, perlu evaluasi dan perhitungan ulang berdasarkan real cost RS pemerintah dan swasta.

Sebagai penutup, saya tegaskan bahwa saya tidak berani menyimpulkan jika “RS yang kerjasama dengan BPJS banyak yang untung”, disamping adanya beberapa berita bahwa RS Privat MERUGI setelah kerjasama dengan BPJS, namun kenyataan bahwa sampai hari ini masih banyak (mungkin beberapa) RS Privat yang mau bertahan untuk melanjutkan kerjasama dengan BPJS Kesehatan juga tidak bisa diabaikan. Mungkin ada banyak faktor yang melatarbelakanginya. Wallahu A’lam Bishawab….

Salam,

Tri Muhammad Hani
RSUD Bayu Asih Purwakarta
Jl. Veteran No. 39 Kabupaten Purwakarta – Jawa Barat
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