Fraud Prevention in Implementation in National Health Insurance Kendari City, Indonesia

Suhadi, Muh. Kardl Rais, Zainuddin Maidin, Alimin and Sukri Palutturi
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Suhadi: Haluoleo University, Kendari, Indonesia
Muh. Kardl Rais: Hasanuddin University, Makassar, Indonesia
Zainuddin Maidin: Hasanuddin University, Makassar, Indonesia
Alimin: Hasanuddin University, Makassar, Indonesia
Sukri Palutturi: Hasanuddin University, Makassar, Indonesia

International Journal of Health and Medical Sciences, 2015, vol. 1, issue 1, 17-21

Abstract: . By the enactment of the National Health Insurance (NHI) on January 1st, 2014, the fraud incident potential will be found. If the premium of NHI is approximately 38.5 trillion with the estimation of the fraud figure of 5 %, the amount of loss will reach 1.8 trillion. The finding of the Indonesian Corruption Watch (ICW) between 2006-2008, there were 54 cases with the state loss reached Rp.128 billion. The fraud mode is in the forms of the fund mark up, drug manipulation, data embezzlement, fund corruption, fictive drugs and health instruments, authority abuse, and bribery. In 2008, PT. Askes marked up the claim as much as Rp.1.2 trillion. In the Regional General Hospital of Bau-bau City, South East Sulawesi Province, it is obtained that the drug claim reached Rp.66 million for patients who were hospitalized in the long stay ward for one day. The research used the qualitative approach. The research was conducted in the hospital, PHC, BPJS, private clinic, and patients in Kendari City in 2014. The research informants included the Hospital Director, PHC Head, BPJS head, clinic doctors, and patients. The research result indicates that the fraud potential and perpetrators are discovered in the Health Service Providers (HSP) and patients, while in BPJS, they do not exist. For the hospital fraud indications, 12 cases are discovered in Kendari City. they are not discovered in PHC. The discovery and prevention of the fraud indications can be carried out through the administrative and medical verifications. For example, the repeated readmission, dual card charges between hospitals. The driving factor in the fraud incident is in the form of the HSP's ignorance because the medical officials have not been accustomed to the diagnosis system in accordance with BPJS guidelines, whereas the intentional factor is not found. The research concludes that generally, the fraud potential is discovered in HSP and patients, it is not found in BPJS. The discovery and prevention of the fraud indications can be carried out through the administrative and medical verifications. The driving factor of the fraud incident is in the form of the HSP's ignorance because the medical officials have not been accustomed to the diagnosis system, while the intentional factor is not found. Suggestion: It is necessary to control the expenditure systematically to prevent the fraud, either in the HSP or patients, the fraud socialization to the HSP and community.

Keywords: Prevention; Fraud; National Health Insurance (search for similar items in EconPapers)
Date: 2015
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Persistent link: https://EconPapers.repec.org/RePEc:apa:ijhmss:2015:p:17-21

DOI: 10.20469/ijhms.30003

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