Integrasi Sistem Informasi dan Pendekatan Kebijakan untuk Mencegah Fraud dalam Program Jaminan Kesehatan Nasional di Indonesia: Tinjauan Literatur
DOI:
https://doi.org/10.31004/joecy.v6i1.6859Keywords:
Pencegahan fraud, Jaminan Kesehatan Nasional, sistem informasi, kebijakan kesehatanAbstract
Program Jaminan Kesehatan Nasional (JKN) di Indonesia telah menghadapi tantangan signifikan terkait praktik kecurangan (fraud) sejak implementasinya pada tahun 2014. Kajian literatur sistematis ini bertujuan untuk menelaah integrasi antara sistem informasi dan pendekatan kebijakan dalam mencegah fraud pada program JKN. Penelitian ini menganalisis literatur yang ada mengenai mekanisme pencegahan fraud dalam sistem asuransi kesehatan Indonesia, dengan fokus pada peran teknologi informasi dan intervensi kebijakan dalam memerangi praktik kecurangan. Pencarian literatur dilakukan secara sistematis pada berbagai basis data, termasuk PubMed, Scopus, Google Scholar, serta basis data akademik nasional Indonesia, mencakup publikasi antara tahun 2014 hingga 2024. Kata kunci pencarian meliputi kombinasi istilah seperti “ Indonesia”, “ JKN”, “ BPJS”, “ health insurance fraud”, “ information system”, dan “ fraud prevention”. Hasil tinjauan mengidentifikasi beragam bentuk fraud yang memengaruhi program JKN, termasuk kecurangan klaim, pemalsuan identitas, serta pelanggaran yang dilakukan oleh penyedia layanan kesehatan. Intervensi berbasis sistem informasi, seperti pemantauan secara real-time, analisis data, dan sistem verifikasi digital, menunjukkan potensi besar dalam mendeteksi serta mencegah terjadinya fraud. Sementara itu, pendekatan kebijakan seperti kerangka regulasi, sistem sanksi, serta mekanisme koordinasi antar-pemangku kepentingan diidentifikasi sebagai komponen penting dalam strategi pencegahan fraud yang komprehensif. Pendekatan terpadu yang mengombinasikan sistem informasi yang kuat dengan kerangka kebijakan yang efektif menjadi krusial dalam mencegah praktik fraud pada program JKN. Penelitian di masa mendatang perlu difokuskan pada pengembangan solusi berbasis teknologi yang sesuai dengan konteks budaya serta mampu menjawab tantangan unik dalam sistem pelayanan kesehatan Indonesia.
References
Anti-Corruption Commission Indonesia. (2022). Annual report on corruption trends in Indonesia 2021. Komisi Pemberantasan Korupsi Republik Indonesia.
Ardini, L., Machmuddah, Z., & Utomo, S. D. (2020). Fraud detection in Indonesia national health insurance implementation: A phenomenology experience from hospital. International Journal of Scientific & Technology Research, 9(4), 1455-1462.
Bauder, R., Khoshgoftaar, T. M., & Seliya, N. (2017). A survey on the state of healthcare upcoding fraud detection research. Health Services and Outcomes Research Methodology, 17(1), 31-55. https://doi.org/10.1007/s10742-016-0167-x
BPJS Kesehatan. (2022). Digital transformation strategy 2022-2025: Enhancing healthcare service delivery through technology. Badan Penyelenggara Jaminan Sosial Kesehatan.
BPJS Kesehatan. (2023a). Annual report 2022: Universal health coverage progress and challenges. Badan Penyelenggara Jaminan Sosial Kesehatan.
BPJS Kesehatan. (2023b). Internal audit report on healthcare fraud prevention mechanisms. Internal Audit Division, Badan Penyelenggara Jaminan Sosial Kesehatan.
BPJS Kesehatan. (2023c). Laporan Tahunan BPJS Kesehatan 2022. BPJS Kesehatan. https://www.bpjs-kesehatan.go.id/bpjs/pages/detail/2023/10
Centers for Medicare & Medicaid Services. (2020). Fraud Prevention System Annual Report. U.S. Department of Health and Human Services. https://www.cms.gov/newsroom
Corruption Eradication Commission Indonesia. (2021). Analysis of gratification control systems in the health sector. Komisi Pemberantasan Korupsi Republik Indonesia.
Dartanto, T., Harimurti, P., & Ng, A. (2016). The political economy of universal health coverage in Indonesia: A systematic review. Health Policy and Planning, 31(8), 1102-1114.
European Healthcare Fraud & Corruption Network. (2021). Healthcare fraud in Europe: Trends, patterns, and prevention strategies. EHFCN Publications.
Gunadi, P., Hasan, S., Arda, I. N., Rahayu, E. D., & Andika, Z. (2024). Implementation of digital verification systems for fraud prevention in the National Health Insurance program: A case study at Syariah Hospital Jakarta. Media Riset Bisnis Ekonomi Sains dan Terapan, 2(4), 1-8.
Hana, M. Z., & Prabowo, H. Y. (2025). Implementing fraud prevention and detection strategies in Indonesia's National Health Insurance: A case study at BPJS Health Yogyakarta. At-Taradhi: Jurnal Studi Ekonomi, 16(1), 65-85.
Higgins, J. P. T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M. J., & Welch, V. A. (Eds.). (2023). Cochrane handbook for systematic reviews of interventions version 6.4. Cochrane. www.training.cochrane.org/handbook
Indonesian Medical Association. (2022). Ethics committee report: Professional violations in medical practice. Ikatan Dokter Indonesia.
Indonesia Ministry of Health. (2018). Regulation of the Minister of Health Number 36 of 2015 concerning Prevention of Fraud in the Implementation of Health Insurance Programs. Ministry of Health Republic of Indonesia.
Kementerian Kesehatan Republik Indonesia. (2019). Permenkes No. 16 Tahun 2019 tentang Pencegahan dan Penanganan Kecurangan dalam Program JKN. https://peraturan.bpk.go.id/Home/Details/140641/permenkes-no-16-tahun-2019
Kim, J., Lee, J., & Lee, J. (2019). Detecting healthcare fraud and abuse with rule-based outlier detection. Expert Systems with Applications, 112, 83-92. https://doi.org/10.1016/j.eswa.2018.06.032
Korea National Health Insurance Service. (2021). 2020 national health insurance statistical yearbook. National Health Insurance Service.
Mahendradhata, Y., Trisnantoro, L., Listyadewi, S., Soewondo, P., Marthias, T., Harimurti, P., & Prawira, J. (2017). The Republic of Indonesia health system review (Vol. 7, No. 1). WHO Press.
Marriska, K., Dewi, R. S., & Ananda, F. (2021). Policy strategies to reduce fraud in BPJS claims based on the Minister of Health Regulation. Indonesian Journal of Health Policy and Administration, 6(2), 78-89.
Ministry of Administrative and Bureaucratic Reform. (2021). Guidelines for public service innovation and digital transformation. Kementerian Pendayagunaan Aparatur Negara dan Reformasi Birokrasi.
Ministry of Communication and Informatics. (2023). Digital transformation roadmap for public services 2023-2025. Kementerian Komunikasi dan Informatika Republik Indonesia.
Ministry of Health Indonesia. (2021). Strategic plan of Ministry of Health 2020-2024: Towards healthy Indonesia. Kementerian Kesehatan Republik Indonesia.
Ministry of Health Indonesia. (2022a). Indonesia health profile 2021: Progress towards universal health coverage. Kementerian Kesehatan Republik Indonesia.
Ministry of Health Indonesia. (2022b). Health facilities and services statistics 2021. Kementerian Kesehatan Republik Indonesia.
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097.
National Health Care Anti-Fraud Association. (2022). The challenge of health care fraud: 2021 annual report. NHCAA Publications.
Ng, A., Farooqui, M. A., & Hamers, F. F. (2019). Universal health coverage in Indonesia: Concept, progress, and challenges. Global Health Action, 12(1), 1618853.
NHS Counter Fraud Authority. (2020). Annual Report and Accounts. UK Government. https://cfa.nhs.uk/
Odonkor, G., Sablah, E., & Frimpong, J. (2020). Health insurance fraud: Typologies and emerging trends. Journal of Financial Crime, 27(4), 1253-1271. https://doi.org/10.1108/JFC-05-2020-0083
OECD. (2017). Tackling wasteful spending on health. OECD Publishing. https://doi.org/10.1787/9789264266414-en
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., ... Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71.
Pisani, E., Olivier Kok, M., & Nugroho, K. (2017). Indonesia's road to universal health coverage: A political journey. Health Policy and Planning, 32(2), 267-276.
Pramono, D., Wicaksono, A., & Sari, N. (2021). Anti-fraud policy in Indonesia's National Health Insurance: A review. Jurnal Kebijakan Kesehatan Indonesia, 10(3), 150-162. https://doi.org/10.7454/jki.v10i3.3261
Putra, A. D., & Sari, D. P. (2019). Study of fraud prevention in Indonesia National Health Insurance Program: A collaborative governance approach. Vision 2020: Sustainable Economic Development and Application of Innovation Management, 1-12.
Rahman, S., Kusuma, H., & Wardani, L. (2022). The implementation of fraud prevention on the National Health Insurance at Salewangan Maros Hospital, Indonesia: A qualitative study. International Journal of Health Sciences, 6(3), 1045-1058.
Republic of Indonesia. (2018). Government regulation No. 82 of 2018 on health insurance. State Secretariat of the Republic of Indonesia.
Santoso, B., Prawira, Y., & Suharto, S. (2018). Information system for prevention of National Healthcare Insurance fraud among inpatients of advanced referral health services. Academic Hospital Journal, 2(1), 23-31.
Setiawan, D., Budiharto, P., & Kusuma, A. (2023). Analysis of fraud prevention efforts in JKN claims against potential unsuitable claims at Al Ihsan Regional General Hospital. International Journal of Psychology and Health Science, 4(2), 112-125.
Sood, N., Shrestha, A., Bendavid, E., & Wagner, Z. (2017). Health insurance fraud in low- and middle-income countries. Health Policy and Planning, 32(7), 891-901. https://doi.org/10.1093/heapol/czx039
Sparrow, M. K. (2016). Fraud in the health care sector: A troubling status report. Journal of Insurance Regulation, 35(4), 1-32. https://doi.org/10.2139/ssrn.3056972
Statistics Indonesia. (2022). Statistical yearbook of Indonesia 2021. Badan Pusat Statistik.
Suryani, E., Hendrawan, R. A., & Philip, R. (2020). Potential fraud and its prevention in the implementation of national health insurance at Dadi Regional Hospital. International Journal of Multicultural and Multireligious Understanding, 7(8), 234-248.
Transparency International. (2019). The ignored pandemic: How corruption in healthcare systems is undermining universal health coverage. Transparency International. https://ti-health.org
Utami, S. R., Handayani, P. W., & Pinem, A. A. (2021). Application of Failure Mode and Effects Analysis in managing medical records for accuracy of INA-CBGs health insurance claims in a tertiary hospital in Indonesia. International Journal of Health Planning and Management, 36(4), 1332-1347.
Wibowo, A., Sulistyaningtyas, T., & Rakhmawati, N. A. (2023). Evaluation of fraud prevention policies in the National Health Insurance System in Indonesia: Narrative literature review. Public Health Indonesia, 9(4), 128-140.
Wicaksono, A., & Purnamasari, D. (2020). Fraud prevention in Indonesian health insurance: Lessons from global practices. Kesmas: National Public Health Journal, 15(4), 200-208. https://doi.org/10.21109/kesmas.v15i4.4507
World Health Organization. (2017). The Republic of Indonesia Health System Review. Health Systems in Transition, 7(1), 1-291.
World Health Organization. (2019). Strategic action plan on anti-fraud measures in health systems. WHO. https://www.who.int/publications
World Health Organization. (2022). Universal health coverage country profile: Indonesia. WHO Press.
Yanti, N. P. E. D., Suarjana, I. K., & Wirakusuma, M. G. (2022). Fraud triangle analysis in the context of health insurance claims: Evidence from Indonesian hospitals. Asian Journal of Accounting Research, 7(2), 145-159.
Zulkarnain, A., Supriadi, S., & Mahendra, G. (2021). Digital transformation in fraud prevention: A case study of Indonesia's National Health Insurance Program. International Journal of Advanced Computer Science and Applications, 12(8), 267-274.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Inayyah Nur Fitry Sirajuddin, Fithri Handayani Lubis
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
