Uncovering Fraud in Health Center Capitation Fund Planning
DOI:
https://doi.org/10.24843/JIAB.2024.v19.i01.p08Keywords:
farud, planning, capitation fundAbstract
This study aimed to investigate fraud in capitation fund management at the Pesisir Health Center in Sanjaya Regency. Capitation funds, where healthcare providers are paid a set amount per patient over a specific period regardless of services rendered, are vulnerable to fraud due to inadequate monitoring. Using qualitative methods and a case study approach, data were collected through observations, documentation, and interviews. Findings revealed that fraud motivations included financial pressures to gain more from the funds. Opportunities for fraud arose from monitoring lapses, and rationalizations were made by perpetrators who deemed their actions justified, mirroring widespread similar misconduct. Additionally, those committing fraud typically possessed the necessary skills and experience to manipulate the system effectively
References
Aboagye, A. (2013). Capitation in Health Care Financing in Ghana. East African medical journal, 90, 156-163.
Adjei, A., Spaan, E., Asante, F. A., Mensah, S. A., & Velden, V. Der. (2018). A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries. Ghana medical journal, 50, 207-219. https://www.ajol.info/index.php/gmj/article/view/150016/139555.
Afifah, L. A. N., Arso, S. P., & Fatmasari, E. Y. (2019). Analisis Mekanisme Pengelolaan Dana Kapitasi Pada Klinik Pratama Di Kecamatan Pedurungan Kota Semarang (Vol. 7, Issue 4). http://ejournal3.undip.ac.id/index.php/jkm
Aikins, M., Tabong, P. T. N., Salari, P., Tediosi, F., Asenso-Boadi, F. M., & Akweongo, P. (2021). Positioning The National Health Insurance For Financial Sustainability And Universal Health Coverage In Ghana: A Qualitative Study Among Key Stakeholders. PLoS ONE, 16(6 June). https://doi.org/10.1371/journal.pone.0253109
Anisa, & Tjaraka. (2019). Lingkungan Pengendalian Pengelolaan Dana Kapitasi di Puskesmas Tanjung Selor Kalimantan Utara. AKTSAR: Jurnal Akuntansi Syariah, 1(2), 275. https://doi.org/10.21043/aktsar.v1i2.5224.
Arisandi, M. Z. (2021). Mekanisme Pengawasan Terhadap Peserta Bpjs Ditinjau Dari Perspektif Hukum Administrasi Negara. Journal of Law (Jurnal Ilmu Hukum), 7(1), 127-139.
Barrientos, A. (2011). Social Protection And Poverty. Int J Soc Welf. https://doi.org/10.1111/j.1468-2397. 2011.00823.x
Berwick, D. M. (1996). Payment By Capitation And The Quality Of Care. N eng J Med, 335(16), pp.1227-1231.
Bianca, G., Anjani Septiana, M., & Gita Cinta, N. (2020). Analisis Pengelolaan Dana Kapitasi JKN Pada Fasilitas Kesehatan Tingkat Pertama (FKTP).
Brisimi, T. S., Lopez, V., Rho, V., Sbodio, M., Picco, G., Kristiansen, M., Segrave-Daly, J., & Cullen, C. (2020). Ontology-guided Policy Information Extraction for Healthcare Fraud Detection. Studies in Health Technology and Informatics, 270, 879–883. https://doi.org/10.3233/SHTI200287
Chaix-Couturier, C., Durand-Zaleski, I., Jolly, D., & Durieux, P. (2000). Effects of Financial Incentives on Medical Practice: Results From a Systematic Review of The Literature and Methodological Issues. In International Journal for Quality in Health Care (Vol. 12, Issue 2).
Cox, T. (2011). Exposing the true risks of capitation financed healthcare. Journal of Healthcare Risk Management, 30(4), 34-41.
Creswell, J. W. (1998). Qualitative Inquiry and Research Design: Choosing Among Five Tradition. SAGE Publications.
Demetriades, P., & Owusu-Agyei, S. (2022). Fraudulent financial reporting: an application of fraud diamond to Toshiba’s accounting scandal. Journal of Financial Crime, 29(2), 729-763.
Desmita, E., Yuliani, F., & Adianto. (2022). Pengelolaan Dan Pemanfaatan Dana Kapitasi Jaminan Kesehatan (JKN) FKTP Pemerintah Daerah Kabupaten Kampar Tahun 2018.
Devi, A. D. K., Suryoputro, A., & Sriatmi, A. (2020). Pemetaan Stakeholder Program Pencegahan Fraud Jaminan Kesehatan Nasional di Puskesmas Kota Semarang. Media Kesehatan Masyarakat Indonesia, 19(3), 238-245.
Direktur Jenderal. (2006). Pedoman Lokakarya Mini Puskesmas. Direktur Jenderal Bina Kesehatan Masyarakat Departemen Kesehatan RI.
Fahmi, A. S., & Ayuningtyas, D. (2020). Readiness Analysis of Electronic Information System in Public Health Center as Supporting Tools in Implementation of Fraud Prevention System on UHC Program: Literature Review.
Fikri, I., Putri, R. N., & Ernia, R. (2022). Analisis Kebijakan Pemanfaatan Dana Kapitasi JKN Pada Pegawai Di Puskesmas Talang Ratukota Palembang.
Fitrianeti, D., W. L. , & Yulianti, A. (2017). Penganggaran dan Penerimaan Dana Kapitasi Program JKN di Daerah Terpencil Kabupaten Kepulauan Mentawai Implementation of Breaching And Acceptance Of Health Capitation Funds National Health Care Program In Remote Areas Of Distric Mentawai Islands. Jurnal Penelitian Dan Pengembangan Pelayanan Kesehatan, 1(2), 92–101.
Gatra. (2022). Kasus Puskesmas Bungku Tahap Dua, Lima Tersangka Ganti Rompi.
Geswar, R. K., Nurhayani, & Balqis. (2014). Kesiapan stakeholder dalam pelaksanaan program JKN di Kabupaten Gowa.
Hamzah, A. (2020). Metode Penelitian Studi Kasus Single Case, Instrumental Case, Multicase & Multisite. Literasi Nusantara.
Handayani, N. F. (2022). Pengendalian Pengelolaan Dana Kapitasi Puskesmas Pasrujambe Kabupaten Lumajang Periode Tahun 2019.
Hasri, E. T., Wulan, S., & Djasri, H. (2019). Evaluasi kebijakan kendali mutu dan kendali biaya, pencegahan kecurangan dan kapitasi berbasis komitmen dalam era JKN di provinsi bengkulu menggunakan pendekatan realis evaluasi. Pkmk Fk-Kmk Ugm, 1-12.
Himmayatul, W., Alim, M. N., & Prasetyono. (2017). Potential For Fraud In The Management Of JKN Funds At Community Health Centers (Case study at Community Health Centers in “Hastinapura” District). Asia Pacific Fraud Journal, 3(2). https://doi.org/10.21532/apfj.001.18.03.02.08
ICW. (2018). Desak BPK RI Audit Dana Kapitasi Puskesmas Di Seluruh Indonesia.
Imeldha Anggraini, & Redy, A. S. (2011). Pengaruh Komitmen Organisasi dan Gaya Kepemimpinan Terhadap Hubungan Partisipasi Anggaran dan Kinerja Aparat Pemerintah Daerah. Jurnal Akuntansi Multiparadigma (JAMAL). (Vol. 2).
Istiqomah, A., Jayanti, I. P., Wijayanti, R., Hidayatullah, F., & Oktadewi, F. D. (2023). Implementasi Sistem Pembayaran Kapitasi pada Jaminan Kesehatan Nasional sebagai Strategi dalam Mengatasi Kesenjangan Pelayanan Kesehatan. STOMATOGNATIC-Jurnal Kedokteran Gigi, 20(1), 24-31.
James, B. C., & Gregory P. Poulsen. (2016). The Case for Capitation. Harvard business review 94.7-8 (2016): 102-11.
Johnson, J. M., & Khoshgoftaar, T. M. (2021). Medical Provider Embeddings For Healthcare Fraud Detection. SN Computer Science, 2(4). https://doi.org/10.1007/s42979-021-00656-y
Juwita, R. (2018). Good Governance And Anti-Corruption: Responsibility To Protect Universal Health Care In Indonesia. Hasanuddin Law Review, 4(2), 162–180. https://doi.org/10.20956/halrev.v4i2.1424
Kurniawan, M. F., Siswoyo, B. E., Mansur, F., Aisyah, W., Revelino, D., & Gadistina, W. (2016). Pengelolaan Dan Pemanfaatan Dana Kapitasi (Monitoring Dan Evaluasi Jaminan Kesehatan Nasional Di Indonesia).
Lawrence, T. B. , Mauws, M. K. , Dyck, B. , & Kleysen, R. F. (2005). The Politics Of Organizational Learning: Integrating Power Into The 4I Framework. Acad. Manag. Rev. 30, 180–191. https://doi.org/10.1016/S0889-8561(03)00026-2.
Mackey, T. K., Miyachi, K., Fung, D., Qian, S., & Short, J. (2020). Combating health care fraud and abuse: Conceptualization and prototyping study of a blockchain antifraud framework. Journal of Medical Internet Research, 22(9). https://doi.org/10.2196/18623
Moleong, L. J. (2017). Metodologi Penelitian Kualitatif (Revisi). Remaja Rosdakarya.
Mujiburrahman, M., & Sofyandi, A. (2021). Analisis Komunikasi dan Sumberdaya dalam Implementasi Kebijakan Kapitasi Berbasis Komitmen Pelayanan Badan Penyelenggara Jaminan Sosial (KBK-BPJS). Bima Nursing Journal, 2(2), 90-103.
Nespita, W., Sulastri, D., & Syah, N. A. (2019). Analilsis Implementasi Pengelolaan Dana Kapitasi JKN Oleh Puskesmas di Kabupaten Pasaman Barat. 195–209. https://doi.org/10.22216/jit.2019.v13i3.4737
News, A. (2022). Kejaksaan limpahkan kasus korupsi pembangunan puskesmas di Lembata.
Peraturan Bupati Nomor 44 Tahun 2020. (2020). Peraturan Bupati Tentang Standar Biaya Umum.
Peraturan Menteri Kesehatan Nomor 44 Tahun 2016. (2016). Peraturan Menteri Kesehatan tentang Pedoman Manajemen Puskesmas. 01 September 2016. BN.2016/NO. 1423, kemenkes.go.id : 5 hlm.
Peraturan Presiden Republik Indonesia Nomor 32 Tahun 2014. (2014). Pengelolaan dan Pemanfaatan Dana Kapitasi Jaminan Kesehatan Nasional pada Fasilitas Kesehatan Tingkat Pertama Milik Pemerintah Daerah. 21 April 2014. LN.2014/No.81, LL Setkab : 14 Hlm.
Prativi, A. N., Chriswardani S., & Pawelas A, S. (2015). Analisis Kesiapan Puskemas sebagai Provider BPJS Kesehatan ( Studi di Puskesmas KedungMundu dan Puskesmas Tlogosari Kulon) (Vol. 3, Issue 2). http://ejournal-s1.undip.ac.id/index.php/jkm
Radar Madura. (2022). Penyunatan Dana Berlangsung Sejak 2018 Sampai Sekarang. https://radarmadura.jawapos.com/sanjaya/01/10/2022/penyunatan-dana-berlangsung-sejak-2018-sampai-sekarang.
Sabillah, E. F. (2022). Evaluasi Pengelolaan Dan Pemanfaatan Dana Kapitasi Jaminan Kesehatan Nasional Di Puskesmas.
Sari, F. I., Suroso, I., & Nurhayati, N. (2017). Strategi optimalisasi pengelolaan dana kapitasi jaminan kesehatan nasional puskesmas di kabupaten bondowoso. BISMA: Jurnal Bisnis dan Manajemen, 11(2), 224-236.
Setiawan, J. W., Utami, I., & Pesudo, D. A. A. (2020). Whistleblowing Intention In Organizational Justice & Ethical Climate: An Experimental Study. Jurnal Reviu Akuntansi Dan Keuangan, 10(1). https://doi.org/10.22219/jrak.v10i1.10394
Settipalli, L., & Gangadharan, G. R. (2021). Healthcare fraud detection using primitive sub peer group analysis. Concurrency and Computation: Practice and Experience, 33(23). https://doi.org/10.1002/cpe.6275
Sholihin, M. I., Sakka, A., & Paridah, P. (2016). Pengelolaan Dana Kapitasi BPJS Kesehatan di Puskesmas Watubangga Kecamatan Watubangga Kabupaten Kolaka Tahun 2015 (Doctoral dissertation, Haluoleo University).
Soputan, R., Tinangon, J., & Lambey, L. (2018). Analisis Resiko Kecurangan terhadap Sistem Pengelolaan Dana Kapitasi Jaminan Kesehatan Nasional Di FKTP Pemerintah Kota Bitung.
Syukran, M. (2023). Implementasi Sistem Pembayaran Kapitasi pada Fasilitas Kesehatan Primer: Literature Review. Promotif: Jurnal Kesehatan Masyarakat, 13(1), 7-14.
Tarjo, T., Prasetyono, P., Sakti, E., Pujiono, Mat-Isa, Y., & Safkaur, O. (2023). Predicting Fraudulent Financial Statement Using Cash Flow Shenanigans. Business: Theory and Practice, 24(1), 33–46. https://doi.org/10.3846/btp.2023.15283
Ulum, I. (2008). Akuntansi Sektor Publik. Cetakan ke–3. Malang : UMM Press.
Wolfe, D. T. , & Hermanson, D. R. (2004). The Fraud Diamond: Considering the Four Elements of Fraud.
Yudiyanto, T. K., Kanto, S., & Mardiyono. (2015). Strategi Optimalisasi Implementasi Jaminan Kesehatan Nasional Untuk keluarga miskin di Puskesmas Kedamean Optimalisation Strategy for implementation of the National Health Insurance Assistance Contribution Program or JKN-PBI on Kedamean’s Community Healthcare Center (CHC). 18(2)
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Jurnal Ilmiah Akuntansi dan Bisnis
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
