Analisis Fraud dalam Pelayanan Kesehatan: Tinjauan Literatur atas Studi Kualitatif Pengembangan Healthcare Fraud Governance Model (HFGM) sebagai Kerangka Pencegahan Fraud
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Abstract
Fraud dalam pelayanan kesehatan merupakan masalah serius yang mengancam keberlanjutan pembiayaan, mutu layanan, dan kepercayaan masyarakat terhadap sistem kesehatan. Bentuk fraud yang umum terjadi meliputi klaim palsu, upcoding, overbilling, tindakan medis yang tidak perlu, serta manipulasi administrasi. Penelitian ini bertujuan mengidentifikasi pola fraud pelayanan kesehatan dan mengembangkan model pencegahan berbasis tata kelola. Penelitian menggunakan metode literature review terhadap studi kualitatif periode 2014–2024 yang diperoleh dari PubMed, ScienceDirect, dan Google Scholar. Setelah proses seleksi, delapan artikel dipilih sebagai bahan kajian. Hasil penelitian menunjukkan bahwa fraud dipengaruhi oleh lemahnya pengendalian internal, kegagalan tata kelola, budaya organisasi yang tidak etis, tekanan finansial, dan rendahnya pengawasan. Berdasarkan sintesis temuan, penelitian ini mengusulkan Model Tata Kelola Fraud Pelayanan Kesehatan (HFGM) yang terdiri atas lima pilar, yaitu kepemimpinan etis, pengendalian internal, deteksi fraud digital, budaya etika organisasi, dan mekanisme whistleblowing. Implementasi HFGM berpotensi menurunkan risiko fraud, meningkatkan efisiensi klaim, memperkuat akuntabilitas, dan meningkatkan kepercayaan publik terhadap sistem kesehatan.
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