Risk And Factors of Surgery Fraud Claim PT. Jamsostek at Bekasi Branch
Office, On October 2006-March 2007
Fraud claim is one cause of inefficieny in health expenditure. In
Keywords: intency, inefficiency, moral and ethic, surgeon and verificator
The possible fraud in surgery cases claim of PT.Jamsostek (persero) at Bekasi Branch during 6 months about 25% of the hospitalizaton claims. It leads to the financial risk for the company significantly.
In the administrative fraud there is no macth between the claim with tariff schedule. This type of fraud, usually are done by the claimer of surgery unit of hospital. The medical fraud is no concomittans between the the surgery action and the support data in medical record. In addition, the actors of the fraud is a doctor since he is responsible in writing the the clasification of surgery in medical record.
Factors are related, significantly, to the fraud are doctor, type of surgery, clasificasion of surgery, status of hospitals, and quality of the verificator claim
Potency financial loss related to the fraud is quite big; if it is projected to the public spending for the hospitalization cost. Prevention to the fraud activity is very important to control the inflation of health cost in
To preven the hospital claim fraud some activity could be conducted such as:
- To train the employee of insurance company to improve the knowledge and skill of verification and investigation of claim cases
- To do good hospital credentialling in making the network
- To develop a good team work between Insurance company and the hospitals. Some activities could be conducted such as:
· Disscussion about the cases that are found by the verificator claims
· Evaluation the medical cases and non medical cases that are found in the process of health care services
· Conduct regular meeting between the insurance company and the hospitals to develop a good communication and trust
- To review the tariff of hospitals that could fulfill the expectation of the hospitals and the insurance company