Analysis of Fraud Prevention Efforts in JKN Claims Against Potential Unsuitable Claims at Al Ihsan Regional General Hospital

Abstract

Ineligible claims in the National Health Insurance (JKN) system are a problem and challenge for the sustainability of health financing, especially if they contain elements of fraud that can reduce state finances and the reputation of service providers. This study aims to prevent fraud related to potential invalid claims at Al Ihsan General Hospital by focusing on preventive, detective, and corrective actions. The methods applied include reviewing claim documents, interviewing verification staff, and analyzing the hospital's internal policies. The findings indicate that implementing a multi-tiered verification system before claim submission, using data analytics-based claim review technology, conducting regular training for healthcare and administrative staff, and strengthening internal audits are important strategies to reduce ineligible claims. Additionally, implementing a whistleblowing system and providing training for service providers play a crucial role in reducing fraud risks. These findings emphasize that invalid claims are not always caused by fraudulent intent but can constitute fraud if there is evidence of intentional misconduct. Therefore, a combination of stringent policies, technological support, and a culture of integrity within hospitals is a critical factor in maintaining the accuracy of JKN claims while safeguarding the integrity of the national health financing system.