Systemic Barriers to Preventing Fraud in National Health Insurance (JKN) Claims: Perspectives from Regional Hospitals and BPJS Kesehatan
Keywords:
National Health Insurance; JKN; Claim Fraud; Claim Audit; Anti-Fraud System; Claim Verification.Abstract
Health insurance claims within Indonesia’s National Health Insurance (JKN) scheme are highly vulnerable to fraudulent practices, which may jeopardize the sustainability of the program. Fraud prevention is therefore a critical component of accountable claim management. This study aims to analyze the challenges in implementing the JKN fraud prevention system in hospitals based on existing regulations and current practices. This research adopts a qualitative approach using a case study design. The study was conducted at the BPJS Health office and a hospital located in East Java, Indonesia. Data were collected through document review and in-depth interviews with four informants: one BPJS Health officer, two members of the anti-fraud team, and one member of the hospital’s claim verification team. The data were processed through reduction, presentation, and conclusion drawing. The findings were presented using interview quotations and visual illustrations generated with NVivo 15. The findings reveal that the JKN fraud prevention system in hospitals still faces major challenges, including limited understanding of fraud concepts, minimal utilization of claim detection applications, and inadequate internal audits. The data indicate five groups of outpatient services and five groups of inpatient services based on INA-CBG classifications with the highest fraud potential during the 2022–2024 period. A word cloud visualization highlighted keywords such as “verification,” “application,” “procedure,” and “regulation” as core issues in fraud prevention. Although an anti-fraud team has been established, its implementation remains suboptimal in preventing fraud within JKN claims. The implementation of the JKN fraud prevention system encounters multidimensional challenges, particularly concerning regulatory frameworks, technological support, and human resource competencies. Strengthening digital systems, harmonizing regulations, and providing technical training are essential to enhance monitoring mechanisms and early detection of fraud in JKN claims.
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