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Risk and Factor of Surgery Fraud Claim PT. Jamsostek at Bekasi Branch Office

Selasa, 29 Maret 2011

Risk And Factors of Surgery Fraud Claim PT. Jamsostek at Bekasi Branch

Office, On October 2006-March 2007

Yulherina[1] & Yaslis Ilyas[2]

ABSTRACT

Fraud claim is one cause of inefficieny in health expenditure. In USA is reported 20% of health expenditure contain suspected fraudulent cost. Data for Indonesia is rare because study for health cost fraud in Indonesia is very limited. To get figure and risk on fraud in health cost or expenditure in Indonesia, a study has been run with sample of hospital surgery claim at PT. Jamsostek, Bekasi branch office. Criteria for fraud suspected is inappropriate information that given by hospital and seen at claim document or patient information. There are 177 cases that got surgery at 3 hospital in Bekasi on October 2006- March 2007. All of cases are non maternity surgery. Result of this study are; risk for fraud claim in PT.Jamsostek, Bekasi Branch office is 73,4% of total claim. Factors that related to fraud are type of surgeon specialist, classification of surgery in term of tariff classification, urgency of surgery, and quality of verification person in Jamsostek. This study give information that fraud is potentially could make expenditure for health always increase constantly, because one of the cause is fraud. Fraud is related with moral and ethic of people, and doctors have obligation to avoid cheat patient or other party that responsible for claim payment. Doctors, hospital management and insurance company should work together to reduce risk of fraud and cooperate to make early warning system to minimize impact of fraud claim to health expenditure and quality of service. Awareness of people should be built to make every party in health service could avoid fraud claim.

Keywords: intency, inefficiency, moral and ethic, surgeon and verificator

Conclusion

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 Indonesia

Suggestion

To preven the hospital claim fraud some activity could be conducted such as:

  1. To train the employee of insurance company to improve the knowledge and skill of verification and investigation of claim cases
  2. To do good hospital credentialling in making the network
  3. 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

  1. To review the tariff of hospitals that could fulfill the expectation of the hospitals and the insurance company



[1] Yulherina MD.; MPH Graduate student of School of Public Health, University of Indonesia

[2] Yaslis Ilyas, DDS, MPH, Dr. PH; Senior Lecturer, School of Public Health, University of Indonesia



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