Legal Liability of Hospitals for Fraud in the National Health Insurance Program
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Abstract
This research aims to analyze law enforcement against fraudulent acts committed by hospitals in the implementation of the National Health Insurance (JKN) program. The research method used is normative juridical legal research with statutory and conceptual approaches. Primary legal materials consist of various laws and regulations governing JKN and fraud prevention, while secondary legal materials include books, legal journals, scientific articles, and related study documents. The results of the research indicate that fraud in JKN consists of various deviant practices such as phantom billing, upcoding, inflated bills, and unnecessary treatment, which are driven by the factors of rationalization, opportunity, pressure, and capability based on the Fraud Diamond theory. Law enforcement against fraud is regulated under Minister of Health Regulation Number 16 of 2019, which provides administrative sanctions, but its implementation is not yet optimal because the regulation does not explicitly regulate criminal sanctions. Criminal liability can be imposed through Article 378 and Article 381 of the Criminal Code (KUHP) upon fulfilling the elements of unlawful acts and intent. Dispute resolution can be pursued through non-litigation channels in the form of mediation pursuant to Law Number 24 of 2011 and litigation channels through district courts based on Article 50 of the same law. This research recommends amending Minister of Health Regulation Number 16 of 2019 by adding criminal sanction provisions, strengthening the role of anti-fraud teams, and increasing public legal awareness.
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