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All Journal International Journal of Health and Pharmaceutical (IJHP)
Erlina Puspitaloka Mahadewi
Universitas Esa Unggul, Jakarta Indonesia
Nursing Public Health

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Analysis of Fraud in National Health Insurance in Indonesia: A Literature Review Ice Nurlianti; Syari Winarti; Putih Sujatmiko; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 3 (2025): August 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i3.341

Abstract

The study concern to know how Indonesia implemented the National Health Insurance Program (JKN) as a form of Universal Health Coverage (UHC) aimed at improving public welfare through access to quality and comprehensive health services. However, in its implementation, the program has faced significant challenges in the form of fraud, which has the potential to cause major financial losses and operational inefficiencies. This study used a systematic literature review methodology. This method was chosen to gain a comprehensive understanding of the patterns, causal factors, and effects of fraud reported in numerous studies and cross-national insurance schemes, both public and private. The literature review was conducted using scientific databases such as Google Scholar, PubMed, ScienceDirect, the official Indonesian website and government regulation. The analysis of the study shows that fraud can be committed by various parties involved in the JKN program, including participants, healthcare providers, BPJS Kesehatan officials, and drug/medical device providers, and collusion between these parties may even occur. Common types of fraud include manipulating medical procedures to inflate service costs (upcoding), using fictitious patient identities, forging documents, misusing cards, and billing for services not medically indicated. Challenges in addressing fraud include the scale and complexity of the program, suboptimal technology integration, changing modus operandi of perpetrators, as well as cultural and legal proof challenges.
Health Insurance Policies For Informal Workers: A Review For National Health Insurance Wiwik Sriwahyuni Batubara; Darwono Darwono; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 2 (2025): May 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i2.371

Abstract

Moral hazard in health insurance is a significant institutional issue that concerns the efficiency, sustainability, and equity of health funding systems. This study intends to comprehensively assess the different types of moral hazard, discern the root causes that contribute to it, and examine the regulatory strategies implemented at both national and international levels. This study employed a methodology characterized by a descriptive literature review, which involved a comprehensive analysis of 25 meticulously chosen peer-reviewed articles. The articles in question were published between the years 2014 and 2025, and they were obtained from reputable databases such as Scopus, PubMed, and Google Scholar. The results indicate that moral hazard presents itself in two main forms. Initially, this phenomenon arises among beneficiaries who may engage in excessive consumption and use of healthcare services lacking adequate medical justification. Secondly, it is apparent that healthcare providers may participate in administrative and clinical manipulation, which includes practices such as upcoding, unnecessary hospitalizations, and fraudulent claims. Several contributing factors to moral hazard can be identified, including deficiencies in the design of the INA-CBGs payment system, a lack of health insurance literacy among participants, and insufficient oversight and auditing mechanisms.The findings presented have considerable implications for policymakers, outlining the necessity to improve the national health insurance system. Structural reforms and the implementation of sustainable, multidisciplinary approaches.
Health Insurance Demand Dynamics: Factors Influencing Individual And Family Decisions In Purchasing Insurance Trinarsih Trinarsih; Ilma Widia Hadi; Anah Farkhanah; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 1 (2025): February 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i1.390

Abstract

The study focused on the purpose of this writing is to find out the importance of study examines the dynamics of health insurance demand in Indonesia now, with more focusing on the factors that influence individual and family decisions to purchase insurance policies after the pandemic. Through an in-depth literature analysis, this study explores various economic, social, and policy aspects that contribute to the level of health insurance penetration in a developing country like Indonesia today. Based on a qualitative approach, this study examines how income, education level, and awareness of health risks interact to shape consumer behavior. In addition, this study also considers the impact of government programs and private initiatives in increasing ease of access to health insurance. The results show that there is a significant relationship between the level of financial and health literacy, with the tendency to take and or purchase health insurance. In addition, perceptions of service quality, and trust in insurance service providers are also proven to play an important role in the future. This study provides recommendations for policy makers and industry practitioners to design more effective strategies, in increasing health insurance coverage. This study is expected to contribute to collective efforts to achieve Universal Health Coverage (UHC) in Indonesia soon in the best possible way.
Development of BPJS from Participation, Government Policy, and Technological Aspects After Pandemic Ainur Basirah Mulya; Nurmiati Liska Suspenny; Cucu Wayamah; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 1 (2025): February 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i1.391

Abstract

The pandemic hits all sectors, not only public health but also economic, financial and social aspects. The pandemic in the past makes health development in Indonesia necessary, especially because of its impact on the development of health insurance. Health insurance exists in the form of health protection guarantees, so that participants receive health care benefits, and basic health needs protection is provided to anyone who has paid the insurance premium. The package offered by the National Health Insurance Scheme (JKN) Indonesia goverment is very comprehensive, and includes promotional, preventive, curative and rehabilitative services, all of which are covered and free of charge. Limit costs if they comply with procedures. The JKN program is organized by the Social Health Security Administration (BPJS). Many changes have been made to BPJS in the wake of the Covid-19 pandemic, both in terms of BPSJ membership, government regulations and the technology sector in Indonesia. The methodology of this study is a literature review using international and domestic publications through various databases of research articles, reports and research documents to explain the transition of health insurance to Indonesia after the Covid-19 pandemic. The purpose of this study is to highlight the changes that have occurred in national health insurance, especially BPJS, due to the Covid-19 pandemic. This may add new knowledge that the history of health insurance development in Indonesia was caused by the pandemic disaster and after pandemic.
The Implementation of National Health Insurance Policy At Puri Medika Tanjung Priok Hospital, Jakarta Indonesia Elfrida Novita Savitri; Sondang Dormaida Silaban; Karolina Baransano; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 1 (2025): February 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i1.392

Abstract

The present study reports the comprehensive study on BPJS health recently, as a form of change from PT. Askes in Indonesia, which previously became the organizer of health insurance for all Indonesian people. The JKN program organized by BPJS health aims to improve the social welfare of the community by providing convenience in public services, especially in the health sector. This study aims to examine how the implementation of the national health insurance policy and what are the obstacles in implementing the National Health Insurance policy through the Health Social Security Administering Agency (BPJS) at Puri Medika Hospital, Tanjung Priok, Jakarta, Indonesia. The researcher used a descriptive qualitative research method. The data used in the study were primary and secondary data. Data collection used interview, documentation and observation techniques. The data were analyzed using the Milles and Huberman data analysis model and presented in the form of a TOWS analysis diagram. The implementation of National Health Insurance at Puri Medika Hospital, Tanjung Priok, Jakarta, Indonesia is in the good category. The inhibiting factors for implementation are the limited number of registration officers, lack of public knowledge, and waiting times for health services that still need to be improved.
Analysis of the Possibility of Fraud in the National Health Insurance Program in Indonesia Purwanti Agustini; Romauli Veranica; Dickson Dickson; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 1 (2025): February 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i1.394

Abstract

The study focused on the purpose of finding out the effect and covering fraud in the National Health Insurance. Fraud is an act carried out intentionally to gain financial gain from the JKN program in the National Social Security System, through fraudulent acts that are not in accordance with the provisions of laws and regulations. Health fraud is a serious threat to the world, causing financial misuse of scarce resources and negative impacts on access to health, infrastructure, and social determinants of health. In Indonesia, cases of fraud continue to increase from year to year. The purpose of this study is to find out the latest studies related to the analysis of the opportunities for fraud in health insurance, and how the mechanism for effective prevention and mitigation efforts can be implemented in the implementation of the Health Insurance program in Indonesia. The method used in this journal uses qualitative descriptive through a literature study approach. Opportunities for fraud practices in JKN can be identity falsification, collusion to make false claims, unnecessary health care, excessive invoices, deviations or upcoding of diagnosis codes, document discrepancies, and duplicate claims. The reasons for fraud that usually occur are known as the fraud triangle, namely motivation, opportunity, and rationalization. Result of this study suggested systematic prevention efforts are needed together by health service providers, BPJS, and the Government by implementing the principles of a fraud prevention system, and the formation of a fraud prevention team that is adjusted to the needs for scale of the organization and national, in the future to reduce the negative impacts that occur.
Analysis of BPJS Based National Health Insurance Program Financing For Sectio Caesarea Birth In Indonesia Yulidar Ewi; Siska Hermawati; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 1 (2025): February 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i1.395

Abstract

The study focused on the purpose of finding out about caesarean section delivery is the last alternative to save the mother and fetus when normal delivery is not possible. The increase in caesarean sections worldwide has become a major public health problem, so there needs to be supervision to reduce the number of caesarean sections that are considered unnecessary, one of which is through the classification. The existence of health insurance for the Indonesian people, including BPJS which covers the cost of caesarean operations, allows for an increase in the incidence of caesarean sections. The purpose of the study was to analyze the financing status of the BPJS based National Health Insurance (JKN) program for caesarean section deliveries. This study used quantitative research with a cross sectional, the research sample was mothers who gave birth by caesarean section who used the BPJS National Health Insurance (JKN). This study discusses reporting for one year in 2023, participants who used BPJS national health insurance for caesarean section deliveries were 1117 participants. With the income of BPJS caesarean section services with hospital rates in UHC (Universal Health Care) 2019, will be implemented, while BPJS health according to Indonesia Law number 24 of 2011 is appointed by the government as a health insurance management agency. Data results show that the incidence of caesarean section using National Health Insurance (JKN) is still very high in hospitals. The management of hospitals needs to calculate service costs using unit costs so as not to experience a deficit and anticipate future management.
Inequality of Thought (IOT) on HIV-Aids and LGBT Through Social Media: A Case Study Gen Z in JPC Foundation Erlina Puspitaloka Mahadewi; Mohamad Reza Hilmy; Puspita Chairun Nisa; Ario Pamungkas; Suryari Purnama; Mehmet Ozays; Sundring Pantja Djati
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 1 (2025): February 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i1.401

Abstract

The study focused on the purpose of finding out the effect and covering the views and acceptance of LGBT. Jakarta Indonesia is beginning to be seen clearly, especially the large amount of LGBT content both on television stations and on social media at home and abroad. This is very worrying because shows that LGBT is a risk factor for sexually transmitted infections (STIs) including HIV/AIDS. Unsafe sex, drugs, and many sexual partners, make LGBT people more susceptible to STIs. This study aims to determine the description of knowledge about STIs and attitudes towards the LGBT phenomenon in society, especially among young Gen Z people who still have the impact of inequality of thinking in social media. This study is a qualitative descriptive study conducted from October to December 2024. Data collection used a google form questionnaire. The sample consisted of 75 respondents who were members of the community fostered by the "Jakarta Plus Center (JPC)" Foundation. The sampling technique used was purposive sampling. The data is presented in a frequency table. The results of this study showed that most respondents had good general knowledge about STIs but lacked in more specific knowledge questions in medicine. The acceptance and views of the community in this community towards the LGBT phenomenon are quite low. People in the community consider LGBT to have a negative impact on life, although respondents agree that the human rights of LGBT people as humans must still be protected and respected, as they see on social media.
Co-Authors Ainur Basirah Mulya Anah Farkhanah Ario Pamungkas Cucu Wayamah Darwono Darwono Dickson Dickson Elfrida Novita Savitri Ice Nurlianti Ilma Widia Hadi Karolina Baransano Mehmet Ozays Mohamad Reza Hilmy Nurmiati Liska Suspenny Purwanti Agustini Puspita Chairun Nisa Putih Sujatmiko Romauli Veranica Siska Hermawati Sondang Dormaida Silaban Sundring Pantja Djati Suryari Purnama Syari Winarti Trinarsih Trinarsih Wiwik Sriwahyuni Batubara Yulidar Ewi