Factors Affecting Intensity Whistleblowing of Employees on The Potential Fraud of The National Health Insurance Program

The National Health Insurance Program (Jaminan Kesehatan Nasional /JKN) is an effort by the Government to fulfillment of the basic needs  of public health. However, this program is also susceptible to fraud. Hospital as the Secondary Level Reference Facility that collaborates with the Social Security Agency (Badan Penyelenggara Jaminan Sosial/ BPJS) should establish a fraud prevention system in the JKN implementation. Employees’ positions are at the forefront to reveal various forms of fraudulence including those related to JKN by means of whistleblowing. The ‘Planned Behavior Theory’ analyzes the attitude, subjective norms and behavior control perception factors that affect the intention of JKN-claim related employees' to whistleblow. The purpose of this study was to determine and analyze the influence of attitudinal factors, subjective norms and perceptions of behavioral control on the intention of employee whistleblowing behavior on JKN fraud programs in Hospital X Central Java Province 
This study is a mixed-method study with a ‘sequential explanatory design’ approach. The study was started by using a quantitative method and then continued by means of qualitative method in order to produce a hopefully more complete study result. 
The results of the study prove attitudes (p-value 0.038), subjective norms (p-value 0.040) and perceptions of behavioral control (p-value 0.005) jointly influence the intention of employee whistleblowing. From the results of the OR it can be seen the order of the three independent variables that have the largest to the smallest influence on employee whistleblowing intentions, namely perceptions of behavior control, attitudes and subjective norms. This can be a reference to the management priority scale to make efforts to increase the intention of employee whistleblowing in Hospital X and is expected to be able to change the "silent culture" into and "culture of openness”. 
Jenis penelitian ini adalah penelitian mixed method dengan pendekatan sequential explanatory design. Diawali menggunakan metode kuantitatif dilanjutkan dengan metode kualitatif sehingga diharapkan diperoleh hasil penelitian yang lebih lengkap. 
Hasil penelitian membuktikan persepsi kontrol perilaku, sikap, norma subyektif secara berurut paling berpengaruh terhadap intensi whistleblowing pegawai. Namun masih perlu dilakukan upaya untuk meningkatan persepsi kontrol perilaku, sikap, norma subyektif agar intensi whistleblowing dapat menjadi perilaku whistleblowing pegawai sehingga dampak negatif adanya fraud JKN bagi organisasi dapat dicegah.


INTRODUCTION
The government seeks to guarantee the fulfillment of the basic needs of public health through the National Health Insurance (Jaminan Kesehatan Nasional or JKN) program, but the program is vulnerable to fraud due to changes in the health financing system from the fee for service (out of pocket) to payment with INA-CBG claim payment mechanism (Indonesia Case Base Group) for hospitals.
In the United States the health insurance industry suffers losses of up to hundreds of millions of dollars a year which, if estimated at between 3-7%, result from fraudulent actions.
The Corruption Eradication Commission (Komisi Pemberantasan Korupsi or KPK) released until 2017 the value of the potential fraud of JKN program reached Rp. 3.1 trillion. The potential for cheating occurred in 1.8 million participants in the Social Security Agency of health (Badan Penyelenggara Jaminan Sosial Kesehatan or BPJS Kesehatan). According to the Indonesian Corruption Watch (ICW), it is stated that BPJS is the most crucial thing must be people in the organization who are willing to report if they find abuse of authority or fraud.
The role of employees as a disclosure of potential fraud has also been proven through a survey conducted by the ACFE (Association of Certified Fraud Examiners) in 2014. ACFE states that employees are a valuable source of information for disclosure of the potential for fraud because 47.5% of tips or information is provided by whistleblowers who are employees (ACFE, 2016). So it is important for an organization to use its employees as an early detection / disclosure of the potential for fraud within the organization because failure to prevent and detect fraud has serious consequences for the organization itself (Coffin, 2003).
In the potential fraud of JKN, employees can be used as resources to help prevent, monitor and anticipate all things that could potentially cause fraud of JKN, especially for employees who are directly involved in BPJS claim activities, both DPJP (Dokter Penanggung Jawab Pelayanan or Doctor in Charge of Service), nurses, coders, verification officer and claim officer.
In some companies that have implemented a complaints system, only 32% of the complaints system can be effective. This small amount is due to the fear of the risk of retaliation that is acceptable to complainants (Park et al., 2008) who feel disadvantaged are likely to provide resistance to prevent the whistleblowers from giving reports or testimonies, and even those who feel disadvantaged can threaten and take revenge. However, on the other hand the whistleblower is considered a hero, because he dares to uphold moral values because they will continue to reveal unethical actions even if done by friends and superiors at work, the Whistleblower has a conscience that gives strong clues about the importance of a scandal revealed (Wiryawan et al., 2011).
The conflicting view causes the candidate of the Whistleblower to experience a dilemma in determining attitudes so that it can distort the intention to become a Whistleblower.
This study aims to identify the factors associated with intention to whistleblowing by applying the Theory of Planned Behavior (TPB) concept by Azjen. This theory explains individual factors that form whistleblowing intentions, that a person's behavior arises because of the intention underlying this behavior. The intention is formed because of three factors, namely, attitudes, subjective norms and perceived behavioral control.
The presence of attitudes is when someone evaluates whether the behavior is beneficial (good deed) or not, subjective norms refer to perceptions of social pressure that can be felt to do or not conduct behavior, while the third predictor is percep-because it has the potential to be manipulated. In fact, it is feared that the current deficit of BPJS of Health comes from the problem of claims, as a result, BPJS pays claims greater than the actual costs.
The potential for fraud itself is likely to always exist in the payment system using the claim mechanism (Trisnantoro et al., 2014) and detecting health insurance fraud is important at the same time it is a difficult challenge (Shi et al., 2016).
JKN Fraud can not only cause financial losses for hospitals that are proven to have committed fraud but there is a threat of penalties both administrative and criminal in accordance with Presidential Regulation No. 82 of 2018 and Minister of Health Regulation No. 36 of 2015 and threats from a Joint Decree between KPK, Ministry of Health and BPJS in the form of remedies, civil and criminal. Therefore, this should have been a strong reason for hospitals to avoid JKN fraud and all things that could potentially cause JKN fraud.
Hospital of X is one of the hospitals belonging to the Central Java Provincial Government which is also a BPJS referral hospital so Hospital of X is obliged to provide health services that have been guaranteed by the BPJS in full, but the potential for fraud related to BPJS claims remains.
The return of the BPJS claim file is common in all hospitals but this can be a sign of potential fraud that can occur. From the results of the study in 2016, there were eight unbundling coding files (Irmawati et al., 2016). From the initial survey, information was also obtained that there was still a chance for potential fraud of JKN to occur in Hospital X, Central Java Province.
Since 2016, Hospital X has implemented a fraud reporting system, namely a whistleblowing system (WBS). Whistleblowing system is a system used to accommodate, process and follow up and make reports on information submitted by the reporter regarding violations that occur in the hospital environment. An effective whistleblowing system is believed to be able to reduce fraud in an organization because it can encourage the participation of employees and even the public to be bolder in acting to prevent fraud and corruption by reporting it to those who can handle it. This means that the whistleblowing system is able to reduce the culture of "silence" towards the culture "honesty and openness".
The success of whistleblowing really requires an active role of employees, because members of the organization are valuable resources (Kaplan et al, 2010). In addition, because employees know very well what is happening in their organizations, if employees do not care about this program, then the implementation will fail (Lamb, 2009), so that there tion of behavior control is what is felt, referring to easiness or difficulties faced to conduct behavior.
Research that tested the Planned Theory of Behavior was mostly carried out in institutions related to finance, while research related to whistleblowing within hospital organizations was still very rare.
The purpose of this study was to determine and analyze the influence of attitudinal factors, subjective norms and perceptions of behavioral control on the intention of employee whistleblowing behavior on the fraud of JKN program in Hospital X, Central Java Province.

METHOD
The design of this study uses quantitativequalitative methods (mixed methods). The design used is sequential explanatory design (Creswell, 1994). The use of these two approaches is expected to strengthen and complement each other so that the results of research will be achieved that are not only objective, structured and measurable but will also be achieved with deep and factual research results (Mulyadi, 2011).
In this study, a quantitative method approach was carried out to officers related to BPJS claims starting from DPJP (Doctor in Charge of Service), nurses, coder, verifier, and officers of BPJS claims and qualitative methods to hospital management. Respondents' answers through quantitative methods are done by analyzing data to make a research hypothesis. These results are used as the material in research with quantitative methods for hospital management. The results of the qualitative method are expected to be the answer or response from the results of employee whistleblowing intentions on the potential fraud of the JKN program in Hospital X, Central Java Province.
The method of data collection in this study was conducted by exploring the source of data through primary data, namely the questionnaire, while the technique of data collection by compiling a list of structured questions addressed to respondents. The questionnaire was distributed to 85 respondents. Spread is done directly by visiting each of these fields / sections. The time period for filling out the questionnaire is 2 weeks, and after that period the questionnaire is collected again.
The sampling technique used is the selection of samples using a technique proportionate simple random sampling. But in the process of sampling it is determined how much the sample size will be taken using the Slovin formula, from the formula, then a sample of 85 employees is obtained.
In the next stage, it is carried out by qualitative methods. Determination of data sources in qua-litative research is based on consideration of who is the person who knows best about what is being asked and can provide valid information. The question is related to quantitative results. Sources of data can be taken from other people who have not been selected as samples (Sugiyono, 2017), namely: Head of the General and the head of finance. Informants are the ranks of hospital management and are directly related to the whistleblowing system that is available and related to the activities of JKN claims in Hospital X of Central Java Province.
The initial stage is to use quantitative methods, while the data collection techniques in this study are surveys using questionnaire data collection tools.
This questionnaire was compiled to reveal variable data: where Attitudes are 8 questions, subjective norms are 7 questions, perceptions of behavioral control are 14 questions and intentions are 5 questions, this questionnaire uses the results of other studies tailored to research interests.
In the qualitative method stage, to prove, deepen and expand the quantitative data that has been obtained, then the data is collected through interviews using structured questions with the main informants.
For the purposes of quantitative analysis, the answers to each item favorable instrument can be scored: 1. Strongly Agree 5 2. Agree 4 3. Less Agree 3 4. Disagree 2 5. Strongly Disagree 1 And unfavorable items are given the opposite score. The technique of collecting data through questionnaires, explanations to respondents are needed to provide a correct understanding of questionnaire material to prospective respondents.
The formula that can be used to test construct validity with the correlation of product moment technique while the Reliability Test aims to determine the extent to which the measurement results remain consistent.
The initial phase of research (quantitative), data obtained from respondents' answers will be analyzed in stages, starting from univariate analysis which is used to find out the description of each research variable, which consists of independent variables (attitudes, subjective norms and perceptions of behavioral control) and the dependent variable (Intention of employee whistleblowing). Before the univariate analysis is carried out, the data normality test is done first to see whether the data is normally distributed or not. In this study, the data normality test uses the kologorov-smirnov test. The results of control on Whistleblowing intentions can be seen in the following table: Attitudes, subjective norms and perceptions of behavioral control, each has a significant relationship to whistleblowing intentions. This can be seen from the value of p value = 0.000 both attitudes, subjective norms and perceptions of behavioral control, which means that there is a significant relationship between each independent variable and the dependent variable.
In this study, the results of the bivariate selection of all variables produced p-value <0.25 so that the variable attitudes, subjective norms, and perceptions of behavioral control were included in the multivariate analysis with the enter logistic multiple regression test with a trust level of 95%.
Based on Table 3, the results of multivariate analysis found that three independent variables had a significant effect on whistleblowing intentions. At the attitude value obtained p-value 0.038 (p-value <0.05) The analysis results obtained Odds Ratio (OR) of the attitude variable is 7.128 means that respondents who have a good attitude will have a chance of 7,128 times having a good whistleblowing intention than respondents who have bad attitude. Subjective norm value is obtained p-value 0.040 (p-value <0.05) The analysis results obtained Odds Ratio (OR) from subjective norm variable is 4.620 which means that respondents who have good subjective norms will have the opportunity 4,620 times to have a whistleblowing intention better than respondents who have a bad attitude. On the perception value of behavior control is obtained p-value 0.005 (p-value <0.05). The analysis results obtained Odds Ratio (OR) is 7,239 which means that respondents who have a perception of good behavior control will have the opportunity 7,239 times to have a good whistleblowing intention compared to respondents who have a perception of poor behavior control. From these results, it can also be known that the order of variables that have the most influence on employee whistleblowing intentions is that perception of behavioral control, attitudes and subjective norms.
Based on the data obtained from the quanti-the data normality test show that all variable data are abnormally distributed, so the cut of point used in categorizing data is using the median value. Bivariate analysis is used to analyze the relationship between two research variables (Santoso, 2010). In this study, the relationship between independent variables and dependent variables will be tested using the chi square test. Whereas in the multivariate analysis the variables that become multivariate candidates must show a value of p <0.25 in the results of the bivariate test. The multivariate analysis used is logistic regression analysis using the Enter method. In the final stage (qualitative), data analysis is done by organizing data systematically from interviews, observations, and other materials to improve the understanding of researchers on the case under study and present it as research findings.

RESULTS AND DISCUSSION
Frequency distribution based on whistleblowing intention characteristics is listed in the table below: Table 1 shows that 50 respondents (58.5%) had good whistleblowing intentions, while 35 respondents (41.2%) had poor whistleblowing intentions. Although these results indicate that most respondents have good intentions, the results of reporting from the whistleblowing system that have been in Hospital X since 2016 still show nil results, so there is still a need to increase employees' whistleblowing intentions based on factors of theory of planned behavior, namely attitudes, subjective norms and perceptions of behavioral control. Table  1 also shows the results of the distribution of attitudinal characteristics found in many good categories as many as 63 people (74.1%) compared to the poor category as many as 22 people (25.9%). The results of the subjective norm distribution with a good category are 52 people (61.2%) and a category of less is 33 respondents (38.8%). While the perception of behavior control with good categories is 45 people (52.9%) and the category is less than 40 respondents (47.1%).
The bivariate test results of attitude variables, subjective norms and perceptions of behavioral ses experienced can be stopped as soon as possible.
The tendency of attitudes to support whistleblowing actions will increase the intention to carry out whistleblowing actions.
In the Theory of Planned Behavior, if an employee has a belief that a whistleblowing action will have positive consequences or impacts and he views that the positive consequences or impacts are important or necessary, then he will have a tendency to behave positively to support these actions.
This study has results that are consistent with previous studies conducted by Park & Blenkinsopp (2009);Winardi (2013); Aliyah (2015); research conducted at employees at the BPK (Badan Pemeriksa Keuangan or Supreme Audit Board) where attitude factors have the highest influence among other factors by Bagustianto & Nurkholis (2012) in a study conducted by Budhiningtyas (2015) revealed that positive attitudes towards whistleblowing affect the intention of employees to do whistleblowing.
The results of interviews with the main informants regarding subjective norms of whistleblowing were carried out with the head of the general section and the head of the finance department. From the results of the questionnaire, information obtained from good subjective norms that are formed in the environment of employees of the hospital X.
"... Until now, although there have been no reports that have been entered through the WBS, there are reports through other channels that will still be followed up in accordance with the incoming reports, but this is also sometimes difficult if there is no identity so that information is not clearer... "(IU1) ".. Various forms of reports relating to hospital violations including those related to potential fraud of JKN, other than those reported through the system, can also be followed up through tative research method, interviews were then conducted with the management of X Hospital so that it was expected to provide information that could be used to supplement quantitative data.
The results of the interview with the main informant regarding the attitude of the respondents to the whistleblowing, then carried out to the head of the general section and the head of the finance department. From the results of interviews with the main informants, it is known that efforts have been made regarding whistleblowing activities in hospitals so far.

. "(IU2)
A good whistleblowing attitude on respondents can be caused by frequent appeals and socialization regarding whistleblowing on various occasions.
Information in the form of banners related to whistleblowing has also been carried out but has not expanded because there are only a few points in the room of Hospital X, in which the information has not been contained in detail about the information on the whistleblowing channel and the procedure for using the violation reporting.
The implementation of the whistleblowing system in the hospital X which is still limited to recommendations/appeals can be a gap for employees to avoid doing so..
In the attitude component, there is a process of addressing whistleblowing actions that will be beneficial to organizations that if exposed, the los- Maintaining the confidentiality of the whistleblower's identity is a major commitment for management to protect reporters from various unwanted risks. OR results on this variable also show that the perception of behavior control variables has the greatest influence compared to other independent variables on whistleblowing intentions. So that efforts related to the perception of behavioral control for employees can be of more concern besides overcoming various obstacles that exist in the perception of behavioral control In this study, perceptions of behavioral control are employees' beliefs that refer to the ease or difficulty faced by whistleblowing. Ajzen (1991) explains that the more individuals perceive many supporting factors and the fewer inhibiting factors to conduct a behavior, the more control they feel over the behavior and vice versa, if fewer individuals feel supporting factors and many inhibiting factors to do something actions, then individuals tend to perceive themselves in difficult circumstances to carry out these behaviors.
Concern about revenge can be minimized if employees' report through a whistleblowing system, but the whistleblowing system does not yet accommodate anonymous reports, even though the report by writing a clear identity from the reporter has weaknesses for example related to the courage of the reporter to include his identity so that it can raise doubts, especially against the possibility of revenge.
The results of this study support the Planned Behavior Theory which states that one's intention to behave is influenced by perceptions of behavior control. Perception of behavioral control is a very important factor in predicting behavior that is not under the individual's full control. Even though individuals have subjective attitudes and norms that support but execution of behavior still depends on the perception of behavioral control factors. The greater the perception of the opportunities and resources a person has, the smaller the perception of the obstacles a person has, the greater the perception other mechanisms. But even better if the form of reporting can go through the system so that they will be protected from the confidentiality of the reporter... " (IU2) All forms of reports relating to fraud will be followed up in stages to the director, but still directed to using a whistleblowing system. Current efforts at Hospital X are to encourage each employee to consult with his superiors if he sees or is concerned about violations that have an impact on operational safety, financial losses, or other risks and follows up on the report even though it has not been through available mechanisms while continuing to urge use the channel/mechanism.
In addition, the tangible manifestation of management's involvement in prevention of fraud is also carried out by sudden inspections of various fields / parts even to examine documents related to the expectation of potential fraud whether intentional or not, can be avoided as early as possible.
In Theory Planned Behavior, a person has the belief that a person or group in the surrounding environment will accept or not accept the action to be taken, so that if someone believes in what is the norm of the environment or group then someone will follow and shape the behavior according to the wishes of the person or group in the environment. Which means that the environment influences a person's decision to do or not do something. So that if the environment provides strong support for someone to do something, then it is likely someone to do that and the opposite, so that the stronger the subjective norm around the whistleblowing environment, the stronger the intention of employees to do whistleblowing. This result is in line with research conducted by Park & Blekinshopp (2009), Perdana et al (2018, Alvin (2014), Zakaria et al (2016), and Winardi (2013) which showed a significant influence between subjective norms on whistleblowing intentions, as well as a study of Budhiningtyas (2015) which showed an positive influence from subjective norms towards whistleblowing intentions.
The results of interviews with the main informants regarding the perception of behavioral control of the whistleblowing conducted with the head of the general section and the head of the finance department, then obtained information.
"...Of course, if all is proven, then a follow up will be carried out that can be in the form of written verbal reprimands, low, moderate, severe punishments to prove that there is second enforcement of the deterrent effect and th three forms of leadership commitment... " (IU1) of behavioral control possessed (Laksono, 2014). This is in line with Park & Blenkinsopp (2009), Mutmainah (2013, Perdana et al (2018), Alvin (2014), Saud (2016) and Zakaria et al (2016) which can be concluded that the perception of behavioral control has a positive influence on intention to do whistleblowing.