Legal Uncertainty and Claims Disputes Challenge Hospital Governance Under National Health Insurance

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.