Hospital-Based Analysis of Determinants of Health Insurance Fraud Tendency

Background: Fraud in hospital-based health insurance claims within the National Health Insurance (JKN) system poses a serious threat to financial sustainability, service quality, and public trust. Objective: This study aimed to analyze factors associated with fraud tendency in JKN claim billing at hospitals. Methods: An analytic cross-sectional study was conducted from March to June 2025 among 270 hospital personnel involved in JKN services and claim management using total sampling. Data were collected using a structured questionnaire based on the Fraud Diamond Theory. The dependent variable was fraud tendency, while the independent variables included pressure, opportunity, rationalization, and capability. Data were analyzed using chi-square and logistic regression (p < 0.05). Results: Pressure (OR = 3.26; 95% CI: 1.53–6.95) and opportunity (OR = 5.08; 95% CI: 2.36–10.96) were significantly associated with fraud tendency. Rationalization showed a marginal association (p = 0.056), while capability was not significant. Conclusion: Fraud tendency in JKN claims is primarily influenced by psychological and organizational factors, particularly pressure and opportunity, while rationalization showed a marginal association. Strengthening ethical culture and organizational integrity is essential for fraud prevention.