Hospital Fraud in the National Health Insurance Program from a Legal and Governance Perspective
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Abstract
This study examines hospital fraud in the implementation of the National Health Insurance (JKN) from the perspective of public law and administration, with the aim of assessing the adequacy of regulations, enforcement mechanisms, and dispute resolution patterns. The method used is normative legal research with a legislative and conceptual approach, based on an analysis of the National Social Security System Law, BPJS Health regulations, Presidential Regulations on Health Insurance, and Minister of Health Regulation No. 16 of 2019 concerning the prevention and handling of fraud. The results of the study show that hospital fraud occurs in various forms, such as claim manipulation, data falsification, provision of unnecessary services, and irregular tariff arrangements, which in many cases constitute criminal fraud according to the Criminal Code. The driving factors behind fraud can be explained through the Fraud Diamond, which emphasizes the interaction between pressure, opportunity, rationalization, and the perpetrator's ability, reinforced by weak internal controls and a culture of legal compliance. From an enforcement perspective, Minister of Health Regulation No. 16 of 2019 still focuses on administrative sanctions, so the deterrent effect on perpetrators is limited and criminal prosecution is highly dependent on law enforcement officials' interpretation of the provisions of the Criminal Code. Dispute resolution is possible through mediation or lawsuits in district courts, but its effectiveness is highly dependent on the quality of the complaint unit, the transparency of procedures, and accessibility for JKN participants. This study emphasizes the urgency of strengthening regulations, governance, and legal culture to reduce fraud incidents and protect the rights of JKN participants. These findings provide an argumentative basis for policymakers to design comprehensive interventions in line with the mandate of national social security in the constitution.
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