Implementing Fraud Prevention and Detection Strategies in Indonesia’s National Health Insurance: A Case Study at BPJS Kesehatan Yogyakarta
DOI:
https://doi.org/10.18592/taradhi.v16i1.16732Keywords:
BPJS Kesehatan, National Health Insurance Fraud Prevention, Fraud Detection, strategyAbstract
Fraud in public health insurance systems poses an escalating threat to fiscal sustainability, service quality, and public trust. In Indonesia, the National Health Insurance Program (JKN) managed by BPJS Kesehatan operates within a decentralized healthcare system, exposing it to complex fraud risks, particularly in claim processing. This study examines how the BPJS Kesehatan Yogyakarta City Branch implements fraud prevention and detection strategies in accordance with Ministry of Health Regulation No. 16 of 2019 and BPJS Regulation No. 67 of 2021. Adopting a qualitative case study approach, analysis was conducted using NVivo 12 based on in-depth interviews with four key informants. Findings reveal that while fraud control mechanisms are formally established and aligned with national policy, key operational gaps persist, most notably, the inconsistent use of fingerprint-based biometric verification at primary care facilities (FKTP) and the absence of a local Internal Supervision Unit (SPI), which hampers timely oversight. Moreover, identified fraud risks such as claim manipulation, upcoding, and claim fragmentation illustrate the ongoing challenges in translating national anti-fraud regulations into effective local practice. These insights highlight the need for stronger cross-sector coordination and localized audit capacity to enhance fraud governance at the branch level. By offering localized insights into the practical application of national policies, this study contributes new perspectives to the literature on health insurance fraud prevention and provides practical implications for improving accountability in Indonesia’s universal healthcare system. Kecurangan dalam sistem asuransi kesehatan publik merupakan ancaman yang semakin meningkat terhadap keberlanjutan fiskal, kualitas layanan, dan kepercayaan publik. Di Indonesia, Program Jaminan Kesehatan Nasional (JKN) yang dikelola oleh BPJS Kesehatan beroperasi dalam sistem layanan kesehatan yang terdesentralisasi, sehingga menghadapi risiko kecurangan yang kompleks, khususnya dalam proses klaim. Penelitian ini mengkaji bagaimana BPJS Kesehatan Cabang Kota Yogyakarta mengimplementasikan strategi pencegahan dan pendeteksian fraud sesuai dengan Peraturan Menteri Kesehatan No. 16 Tahun 2019 dan Peraturan BPJS No. 67 Tahun 2021. Dengan menggunakan pendekatan studi kasus kualitatif, analisis dilakukan melalui perangkat lunak NVivo 12 berdasarkan wawancara mendalam dengan empat informan kunci. Temuan menunjukkan bahwa meskipun mekanisme pengendalian fraud telah dibentuk secara formal dan selaras dengan kebijakan nasional, masih terdapat celah operasional yang signifikan, khususnya belum konsistennya penggunaan verifikasi biometrik berbasis sidik jari di fasilitas kesehatan tingkat pertama (FKTP) serta belum adanya Satuan Pengawas Internal (SPI) di tingkat cabang yang menghambat pengawasan secara tepat waktu. Selain itu, risiko kecurangan yang diidentifikasi seperti manipulasi klaim, upcoding, dan fragmentasi klaim mencerminkan tantangan yang terus berlangsung dalam menerjemahkan regulasi nasional anti-fraud ke dalam praktik lokal yang efektif. Temuan ini menegaskan pentingnya penguatan koordinasi lintas sektor dan kapasitas audit lokal untuk meningkatkan tata kelola pencegahan fraud di tingkat cabang. Dengan memberikan wawasan kontekstual tentang penerapan kebijakan nasional di tingkat operasional, penelitian ini menawarkan perspektif baru dalam literatur pencegahan fraud asuransi kesehatan dan memberikan implikasi praktis bagi peningkatan akuntabilitas dalam sistem jaminan kesehatan nasional di Indonesia.References
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