Analisis Strategi Manajemen Klaim dalam Menekan Risiko Fraud Asuransi Kesehatan: Analisis Systematic Literature Review
DOI:
https://doi.org/10.32585/jmiak.v8i2.7082Abstract
The National Health Insurance (JKN) program in Indonesia is designed to ensure equitable access to healthcare services for all citizens. However, fraud within the health insurance claim process remains a critical challenge, posing financial risks to the state and undermining public trust in the system. This study aims to analyze claim management strategies for mitigating fraud risk using a systematic literature review (SLR) approach. Literature was sourced from Google Scholar and Semantic Scholar, selected through the PRISMA method, and evaluated using a standardized quality assessment framework. The analysis reveals that key challenges include weak administrative verification, inaccurate coding, and a lack of system integration between hospitals and BPJS. Preventive strategies such as strengthening internal governance, digitizing medical records, enhancing staff competence, and implementing risk governance principles have proven effective in building a more accountable and resilient claim management system.
Downloads
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The copyright to this article is transferred to Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK) if and when the article is accepted for publication under Creative Commons Attribution-ShareAlike 4.0 International License. The undersigned hereby transfers any and all rights in and to the paper including without limitation all copyrights to Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK). The undersigned hereby represents and warrants that the paper is original and that he/she is the author of the paper, except for material that is clearly identified as to its original source, with permission notices from the copyright owners where required. The undersigned represents that he/she has the power and authority to make and execute this assignment.
We declare that:
1. This paper has not been published in the same form elsewhere.
2. It will not be submitted anywhere else for publication prior to acceptance/rejection by this Journal.
3. A copyright permission is obtained for materials published elsewhere and which require this permission for reproduction.
Furthermore, I/We hereby transfer the unlimited rights of publication of the above mentioned paper in whole to Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK). The copyright transfer covers the right to reproduce and distribute the article, including reprints, translations, photographic reproductions, microform, electronic form (offline, online) or any other reproductions of similar nature. The corresponding author signs for and accepts responsibility for releasing this material on behalf of any and all co-authors. After submission of this agreement signed by the corresponding author, changes of authorship or in the order of the authors listed will not be accepted.
Retained Rights/Terms and Conditions
1. Authors retain all proprietary rights in any process, procedure, or article of manufacture described in the work.
2. Authors may reproduce or authorize others to reproduce the work or derivative works for the author’s personal use or for company use, provided that the source and the Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK) copyright notice are indicated, the copies are not used in any way that implies Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK)l endorsement of a product or service of any employer, and the copies themselves are not offered for sale.
3. Although authors are permitted to re-use all or portions of the work in other works, this does not include granting third-party requests for reprinting, republishing, or other types of re-use.
