Exploratory study of factors influencing fraud in the national health service in Buton Islands from a hexagon model perspective

Abstract

Fraud in National Health Insurance of Indonesia, known as Jaminan Kesehatan Nasional (JKN) services, is a problem that can potentially occur in all hospitals in Indonesia. This research aims to explore the factors that influence the occurrence of fraud from the perspective of the Hexagon model in JKN services in several hospitals in the Buton Islands. The Hexagon model, which consists of six key factors—opportunity, ability, arrogance, pressure, rationalization, and collusion—was used to systematically analyze the occurrence of fraud. This research uses an exploratory study method with in-depth interviews with 30 key informants. The research results show that the factor that most influences the occurrence of fraud is opportunity, followed by ability and arrogance. Although the model suggests pressure and rationalization as contributing factors, these elements remain ambiguous in this study due to insufficient supporting data. Collusion plays an important role in fraud but does not always occur. The study resulted in the development of a preliminary predictor model based on the findings, which can be used to identify risk factors for fraud in JKN services. This predictor model can be used to identify risk factors for fraud so that more effective prevention and response can be carried out.