Analysis of the Possibility of Fraud in the National Health Insurance Program in Indonesia
DOI:
https://doi.org/10.51601/ijhp.v5i1.394Abstract
The study focused on the purpose of finding out the effect and covering fraud in the National Health Insurance. Fraud is an act carried out intentionally to gain financial gain from the JKN program in the National Social Security System, through fraudulent acts that are not in accordance with the provisions of laws and regulations. Health fraud is a serious threat to the world, causing financial misuse of scarce resources and negative impacts on access to health, infrastructure, and social determinants of health. In Indonesia, cases of fraud continue to increase from year to year. The purpose of this study is to find out the latest studies related to the analysis of the opportunities for fraud in health insurance, and how the mechanism for effective prevention and mitigation efforts can be implemented in the implementation of the Health Insurance program in Indonesia. The method used in this journal uses qualitative descriptive through a literature study approach. Opportunities for fraud practices in JKN can be identity falsification, collusion to make false claims, unnecessary health care, excessive invoices, deviations or upcoding of diagnosis codes, document discrepancies, and duplicate claims. The reasons for fraud that usually occur are known as the fraud triangle, namely motivation, opportunity, and rationalization. Result of this study suggested systematic prevention efforts are needed together by health service providers, BPJS, and the Government by implementing the principles of a fraud prevention system, and the formation of a fraud prevention team that is adjusted to the needs for scale of the organization and national, in the future to reduce the negative impacts that occur.
References
BPJS, “BPJS Kesehatan,” Badan Penyelenggara Jaminan Sosial.
D. A. D. P. dan D. [1] E. P. Mahadewi, “Health Promotion Healthy Behavior And Religiosity On Sustainable Marketing Of Healthcare Services,” The Seybold Report Journal (TSRJ) , vol. 17, no. 9, pp. 501–513, Sep. 2022.
E. P. , Mahadewi, “Model Perilaku Hidup Bersih Sehat Berkelanjutan Dengan Mediasi Religiositas Di Rumah Sakit Syariah,” Vol. 2024, Mar. 2024.
Bpjs Kesehatan, “Panduan Praktis Tentang Kepesertaan Dan Pelayanan Kesehatan Yang Diselenggarakan Oleh Bpjs Kesehatan Berdasarkan Regulasi Yang Sudah Terbit,” J Vis Lang Comput, 2015.
S. Moriya, W. B. Vogt, and M. Gaynor, “Hospital prices and market structure in the hospital and insurance industries,” Health Econ Policy Law, 2010, doi: 10.1017/S1744133110000083.
Nismawati, U. Umaruzzaman, and E. Puspitaloka Mahadewi, “Implication of BPJS for Private Health Insurance Marketing and Business Competition in Indonesia,” International Journal of Health and Pharmaceutical (IJHP), vol. 2, no. 3, 2022, doi: 10.51601/ijhp.v2i3.96.
Sopian and E. Puspitaloka Mahadewi, “Indonesia Insurance Development with Various Aspects and Prespectives of The Regulatory Approach,” International Journal of Science, Technology & Management, vol. 4, no. 5, 2023, doi: 10.46729/ijstm.v4i5.921.
L. , N. N. , E. S. , & M. E. P. Prayitno, “The Usage Of Government Formulary For BPJS Inpatients With Ischemic Stroke In Indonesia,” International Journal of Health and Pharmaceutical (IJHP), vol. 4, no. 3, pp. 491–498, Jun. 2024.
Prasetya, M. F. Nurdin, and W. Gunawan, “Perubahan Sosial Masyarakat dalam Perspektif Sosiologi Talcott Parsons di Era New Normal,” SOSIETAS, vol. 11, no. 1, 2021, doi: 10.17509/sosietas.v11i1.36088.
E. P. , Mahadewi, METODE RISET BISNIS (Business Research Methods). PT. Literasi Nusantara Abadi Grup.
E. P. Mahadewi, “Investment Risk Management Strategies in Sukuk: A Sharia Management Perspective,” Kontigensi : Jurnal Ilmiah Manajemen, vol. 12, no. 2, pp. 598–608, Dec. 2024, doi: 10.56457/jimk.v12i2.609.
Sopian and E. Puspitaloka Mahadewi, “Indonesia Insurance Development with Various Aspects and Prespectives of The Regulatory Approach,” International Journal of Science, Technology & Management, vol. 4, no. 5, 2023, doi: 10.46729/ijstm.v4i5.921.
E. P. , & S. A. I. Mahadewi, “Enchancing Online Consumer Experience Through Artificial Intelligence In CRM: The Mediating Role of Digital HR,” International Journal of Artificial Intelligence Research, vol. 8, Nov. 2024.
Joint Commission International, “JCI Accreditation Standards for Hospitals,” Joint Commission International Accreditation Standards for Hospitals, 2015.
M. Z. Younis, P. A. Rivers, and M. D. Fottler, “The impact of HMO and hospital competition on hospital costs,” J Health Care Finance, 2005.
T. Şahin, S. Ocak, and M. Top, “Analytic hierarchy process for hospital site selection,” Health Policy Technol, 2019, doi: 10.1016/j.hlpt.2019.02.005.
D. C. Hsia and C. A. Ahern, “Good quality care increases hospital profits under prospective payment,” Health Care Financ Rev, 1992.
The Joint Commission, “National Patient Safety Goals Effective January 1, 2016. Hospital Accreditation Program.,” The Joint Commission, 2016.
E. Puspitaloka Mahadewi, D. Septyanto, M. Reza Hilmy, and F. Tamzil, “The Agility, Adaptation, And Business Optimization, Normal Era For Entrepreneur In Indonesia,” Int.756.
Asari, E. Puspitaloka Mahadewi, I. Marti Ayu, and S. Shorayasari Inernational Journal of Science, Technology & Management, vol. 4, no. 1, 2023, doi: 10.46729/ijstm.v4i1
, “Framing TOWS as Marketing Strategy Determiner of Medical Equipment in PT. Tawada Healthcare Jakarta Indonesia,” International Journal of Science, Technology & Management, vol. 3, no. 6, 2022, doi: 10.46729/ijstm.v3i6.640.
V. Maylia Ardini and E. Puspitaloka Mahadewi, “The Development of Health Insurance and Services in Indonesia,” International Journal of Health and Pharmaceutical (IJHP), vol. 2, no. 3, 2022, doi: 10.51601/ijhp.v2i3.65.
N. Rosnani, R. Hastuti, and E. Puspitaloka Mahadewi, “Analysis Of Demand For Health Insurance Business During The Indonesian Covid Pandemic,” International Journal of Health and Pharmaceutical (IJHP), vol. 2, no. 3, 2022, doi: 10.51601/ijhp.v2i3.106.
Rizki Agustin, E. Puspitaloka Mahadewi, A. Irfandi, and V. Azteria, “The Effect of Service Quality on Customer Satisfaction PT. CAR Life Insurance During the Covid-19 Pandemic,” International Journal of Health and Pharmaceutical (IJHP), vol. 2, no. 2, 2022, doi: 10.51601/ijhp.v2i2.50.
Erlina Puspitaloka Mahadewi, Ade Heryana, Fori Yumita, Mulyo Wiharto, and Lia Amalia, “Framing Improvement of Emergency Services RSKJ Soeprapto Hospital with Lean and WAM Modification,” International Journal of Science, Technology & Management, vol. 2, no. 3, 2021, doi: 10.46729/ijstm.v2i3.220.
E. Puspitaloka Mahadewi and M. Muchtadin, “The Influence of Psychological Capital and Affective Commitment on Organizational Citizenship Behavior of Hospital Staff,” International Journal of Science, Technology & Management, vol. 5, no. 2, pp. 367–372, Mar. 2024, doi: 10.46729/ijstm.v5i2.1081.
G. Ayu, H. Fermansyah, and E. Puspitaloka Mahadewi, “A Study of Managed Care Health System During Pandemic,” International Journal of Science, Technology & Management, vol. 4, no. 4, 2023, doi: 10.46729/ijstm.v4i4.846.
D. Aprianti, Q. ‘Aini, and E. Puspitaloka Mahadewi, “Knowledge Development About The History And Basic Principles Of Health Insurance Business In Indonesia,” International Journal of Science, Technology & Management, vol. 4, no. 4, 2023, doi: 10.46729/ijstm.v4i4.848.
E. Mahadewi, A. Heryana, . Herwanto, R. Astini, and N. Surip, “Marketing Mix Study using Social Media in Hospital,” 2020. doi: 10.5220/0009826004060413.
Heryana, E. P. Mahadewi, and I. Ayuba, “Kajian Antrian Pelayanan Pendaftaran Pasien BPJS di Rumah Sakit Queue Analysis of BPJS Patient Registration Services in Hospital,” Gorontalo Journal of Public Health, vol. 2, no. 1, 2019.
E. P. Mahadewi, A. Heryana, and S. Kuswanti, “Kepuasan Layanan Pasien Jkn Berhubungan Dengan Kinerja Petugas Kesehatan,” Jurnal Bunga Rampai, 2019.
Citrawati, E. Edy Suntoro, and E. Puspitaloka Mahadewi, “Coordination Of Benefit (COB) Program Development Analysis: A Case Study Of Healthcare Insurance In Indonesia,” International Journal of Science, Technology & Management, vol. 4, no. 4, 2023, doi: 10.46729/ijstm.v4i4.845.
S. Putri Agustin, S. Tunom, and E. Puspitaloka Mahadewi, “Factors Analysis Influencing on Demand for Private Health Insurance in Indonesia After Pandemic,” International Journal of Science, Technology & Management, vol. 4, no. 4, 2023, doi: 10.46729/ijstm.v4i4.898.
N. Rizky Perdana, G. Adhasari, and E. Puspitaloka Mahadewi, “Challenges and Implementation of Universal Health Coverage Program in Indonesia,” International Journal of Health and Pharmaceutical (IJHP), vol. 2, no. 3, 2022, doi: 10.51601/ijhp.v2i3.97.
N. Ashri Maunah, B. Sunargo, and E. Puspitaloka Mahadewi, “Application Of The Utmost Good Faith Principle In Life Insurance Business Management In Indonesia,” International Journal of Science, Technology & Management, vol. 4, no. 4, 2023, doi: 10.46729/ijstm.v4i4.844.
E. Puspitaloka Mahadewi, D. Asih, D. Permana, and J. Jumarno, “A Study Of Sustainable Marketing After Pandemic Era In Indonesia,” International Journal of Science, Technology & Management, vol. 5, no. 1, 2024, doi: 10.46729/ijstm.v5i1.1060.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Purwanti Agustini, Romauli Veranica, Dickson Dickson, Erlina Puspitaloka Mahadewi

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.