FRAUD SISTEMIK DALAM JAMINAN KESEHATAN NASIONAL: STUDI KUALITATIF TENTANG KESENJANGAN TATA KELOLA DI KALIMANTAN SELATAN, INDONESIA

Ahyar Wahyudi

doi:10.69957/praob.v6i01.3125

Authors

Ahyar Wahyudi Lembaga Akreditasi Fasilitas Kesehatan Indonesia

DOI:

https://doi.org/10.69957/praob.v6i01.3125

Keywords:

Fraud Asuransi Kesehatan, Jaminan Kesehatan Nasional (JKN), Kesenjangan Tata Kelola, Fraud Sistemik, Pencegahan Fraud Berbasis Risiko, Tata Kelola Kesehatan, Integrasi Data

Abstract

Fraud dalam sistem Jaminan Kesehatan Nasional (JKN) di Indonesia semakin menunjukkan karakter sebagai tantangan tata kelola yang bersifat sistemik, bukan sekadar penyimpangan administratif yang bersifat individual. Penelitian ini bertujuan untuk mengkaji secara kritis kesenjangan tata kelola dalam pencegahan fraud dengan menganalisis laporan fraud JKN tahun 2024–2025, temuan audit, serta literatur ilmiah yang relevan di Kalimantan Selatan. Dengan menggunakan pendekatan kualitatif dalam paradigma post-positivistik, penelitian ini menerapkan analisis tematik kritis menggunakan kerangka multi-gap, yang mencakup empirical gap, policy-implementation gap, institutional gap, data and technology gap, financial control gap, dan literature gap. Hasil penelitian mengungkap adanya kontradiksi mendasar antara tidak adanya kasus fraud yang dilaporkan dan adanya kelemahan sistemik yang signifikan sebagaimana diidentifikasi dalam laporan audit. Paradoks tersebut mencerminkan underreporting dan kegagalan deteksi, bukan efektivitas pengendalian fraud. Fraud dalam sistem JKN muncul sebagai fenomena sistemik yang dibentuk oleh pengaturan kelembagaan yang terfragmentasi, lemahnya integrasi data, keterbatasan kapasitas analitis, serta struktur insentif yang tidak selaras yang melekat dalam sistem pembiayaan kesehatan. Selain itu, pendekatan teoretis yang dominan, seperti fraud triangle dan moral hazard, tidak memadai untuk menangkap kompleksitas tersebut karena terutama menekankan perilaku individu dengan mengabaikan dimensi struktural dan tata kelola. Penelitian ini mengembangkan konseptualisasi “fraud as system failure” dan memperkenalkan gagasan governance illusion, yaitu kondisi ketika rendahnya pelaporan fraud menutupi kerentanan yang mendasari sistem deteksi. Penelitian ini mengusulkan pergeseran menuju model pencegahan fraud berbasis risiko dan berbasis data dengan menekankan tata kelola yang terintegrasi, analitik prediktif, serta mekanisme deteksi dini. Penguatan interoperabilitas data, pendefinisian ulang peran operasional tim pencegahan fraud, serta peningkatan validasi sebelum klaim (pre-claim validation) merupakan aspek penting dalam membangun sistem tata kelola kesehatan yang lebih adaptif, akuntabel, dan tangguh.

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