Irmawati Mathar, Oktia Woro Kasmini Handayani, Evi Widowati, Intan Zainafree
The National Health Insurance (JKN) program in Indonesia faces a significant challenge in preventing both administrative and clinical claims misconduct. The early detection system and internal monitoring mechanisms in hospitals are still not optimal, leading to potential misconduct, such as upcoding, unbundling, and diagnostic code input errors. Limited human resources, technological infrastructure, and integration of procedures are the main obstacles. This study aims to analyze the need for the development of a misconduct prevention system for JKN claims at Hospital X, as well as to develop and test a web-based misconduct prevention system that can support the claim verification process effectively. This research uses a Research and Development (RandD) approach with the ADDIE model, which includes the Analysis, Design, Development, and Implementation stages. Data was collected through in-depth interviews with four key informants directly involved in the misconduct claims and prevention process, as well as analysis of policy documents and secondary data from BPJS Kesehatan. The root of the problem analysis shows six main factors causing the ineffective prevention of JKN misconduct, namely: human resources, systems and equipment, procedures, funding, supervision and regulation, and the organizational environment. It was found that the hospital's information system was not able to detect indications of misconduct automatically, and did not have an internal early warning system. Based on the results of the needs analysis, a web-based JKN Anti-Misconduct System was developed with three types of users (admin, medical record officer, and claim verifier). The web-based misconduct prevention system developed can help the process of verifying JKN claims in hospitals faster, more accurately, and more standardized. This system can be an instrument to support internal oversight and claims audits, while strengthening transparent and accountable health financing governance. Further implementation on a broader hospital scale is recommended to assess its long-term effectiveness and integration with the BPJS Kesehatan system. © 2025, Ecozone, OAIMDD. All rights reserved.
Program Studi D3 Perekam dan Informasi Kesehatan, Bhakti Husada Mulia, Indonesia; Program Studi Doktor Ilmu Kesehatan Masyarakat, Fakultas Kedokteran, Universitas Negeri Semarang, Indonesia
