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The National Health Insurance Program (JKN) is implemented with many policies. One of the policies of the JKN program is controlling the quality and cost of health services, a policy on controlling fraud in health services. The objective is to evaluate the effectiveness and sustainability of fraud prevention policies in improving the quality of hospital services in Malang. This study uses a realist evaluation (RE) approach, namely the evaluation of the form of context-mechanism-outcome (CMO) configuration. This approach is to understand the mechanism of what happened and the context in which a program can run or not. The research object was a hospital in Malang with research subjects being the director of the hospital, the deputy director/head of service and support, the deputy director/head of finance, the head of the anti-fraud team, the head of the quality and cost control team, and the head of insurance/casemix. The sample selection used purposive sampling and data collection through interviews, Data was collected using triangulation techniques through analysis of Minister of Health regulation number 16 of 2019. Result findings, that the hospital already has a Fraud Prevention Team as a technical requirement to extend cooperation with BPJS Kesehatan. The structure and functions of the Team have not been realized in a stipulation containing job descriptions, responsibilities and authorities. Hospitals also do not yet have policies, guidelines, standard operating procedures and work programs. Conclusion, that the context-mechanism-outcome aspect of the fraud prevention policy in the JKN program in hospitals is not working.
Widodo et al. (Sat,) studied this question.