Detection of Healthcare Fraud in The National Health Insurance Program Based on Cost Control

Abstract

Fraud in healthcare services has the potential to reduce the quality of health services, harming patients, and state finances. However, the implementation of fraud prevention in healthcare services has not been fully carried out. The purpose of this study is to determine the cost control-based fraud detection algorithm and detect potential healthcare services fraud in hospitals. The study was conducted at 4 hospitals in East Java-Indonesia. Data retrieval is done by the method of documentation and interviews. With interactive analysis generated, 10 cost control-based algorithms that can be used to detect fraud potential in the hospitals. Based on the time series linear regression analysis, the results show that the data groups that can show the fraud potential in the sample hospitals are (i) outpatient cases with special procedures; (ii) inpatient cases with special drugs; (iii) outpatient cases with special drugs; and (iv) inpatient cases with special prosthesis. Data groups that have not been proven to have the fraud potential are (i) a comparison of the number of JKN inpatients with the number of bills of INA-CBGs inpatients; (ii) comparison of the number of JKN outpatients with the number of bills of outpatient INA-CBGs; (iii) disease severity level; (iv) Inpatient cases bills to BPJS Health; (v) Outpatient case bills to BPJS Health; and (vi) inpatient cases with special procedures.

Quality Control of Health Services of The National Health Insurance Era in East Java - Indonesia: Barriers and Strategy

“…Fraud in the health service has the potential to degrade the quality of health care, harming patients and the country's finances. However, the implementation of fraud prevention in health services has not been fully implemented [15]. The results of external factor analysis show that the threat of health service quality…”

“…Hospitals must be completely quality oriented towards their services, while BPJS Health with its INA-CBGs rates requires hospitals to provide efficient health services that can sometimes degrade quality. This fact encourages fraud in hospitals[15].…”