Abstract
Fraud in the National Health Insurance program (JKN) has become one of the challenges faced by the government because it can harm the state finances and negatively impact the decline in the quality of health services. This research aims to identify triggering factors, inhibiting factors, and also strategies in preventing fraud in the JKN program. The study was conducted using the scoping review method according to the Arksey & O'Malley guidelines by searching 5 electronic databases and finding 2,622 articles. The literature search results were performed according to PRISMA-Scr, and 20 articles were analyzed in this study. The study results identified the triggering factors for fraud in the JKN program, namely the lack of understanding of the diagnosis system established by BPJS Kesehatan, dissatisfaction with the INA-CBGs system, insufficient internal supervision and control, limited resources and training for coding, financial factors, and behavioral and social factors. Meanwhile, the inhibiting factors for fraud in the JKN program include internal control, education and socialization, the implementation of SOPs and clinical pathways, as well as work culture and code of ethics. Fraud prevention strategies that can be implemented include strengthening internal controls, enhancing competencies and resources, formulating fraud prevention policies and guidelines, optimizing information technology in detecting fraud through the use of AI and machine learning, as well as reinforcing organizational culture and ethics.
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Bahasa Abstract
Fraud dalam program Jaminan Kesehatan Nasional (JKN) menjadi salah satu tantangan yang dihadapi oleh pemerintah karena dapat merugikan keuangan negara dan memberikan dampak negatif terhadap penurunan kualitas pelayanan kesehatan. Penelitian ini bertujuan untuk mengidentifikasi faktor pemicu, faktor penghambat, dan juga strategi dalam melakukan pencegahan fraud pada program JKN. Studi dilakukan dengan metode scoping review sesuai pedoman Arksey & O'Malley dengan melakukan penelusuran pada 5 database elektronik dan menemukan 2.622 artikel. Hasil penelusuran literatur dilakukan sesuai PRISMA-Scr dan sebanyak 20 artikel dianalisis dalam studi ini. Hasil studi mengidentifikasi faktor pemicu terjadinya fraud dalam program JKN yaitu kekurangpahaman tentang sistem diagnosis yang telah ditetapkan oleh BPJS Kesehatan, adanya ketidakpuasan terhadap sistem INA-CBGs, kurangnya supervisi dan pengawasan internal, keterbatasan jumlah sumber daya dan pelatihan untuk pengkodean, faktor finansial, serta faktor perilaku dan sosial. Sedangkan faktor penghambat terjadinya fraud dalam program JKN antara lain adanya pengendalian internal, pendidikan dan sosialisasi, penerapan SOP dan clinical pathway, serta budaya keja dan kode etik. Strategi pencegahan fraud yang dapat dilakukan yaitu melalui penguatan pengendalian internal, peningkatan kompetensi dan sumber daya, penyusunan kebijakan dan pedoman pencegahan fraud, optimalisasi teknologi informasi dalam mendeteksi fraud melalui penggunaan AI maupun machine learning, serta penguatan budaya organisasi dan etika.
Recommended Citation
Sam Tito, Julius and Siregar, Kemal Nazaruddin
(2024)
"Faktor Pemicu dan Penghambat Fraud dalam Program Jaminan Kesehatan Nasional dan Strategi Pencegahannya: Sebuah Scoping Review,"
Jurnal Ekonomi Kesehatan Indonesia: Vol. 9:
No.
2, Article 5.
DOI: 10.7454/eki.v9i2.1124
Available at:
https://scholarhub.ui.ac.id/eki/vol9/iss2/5
