SYSTEM FOR DETECTION OF NATIONAL HEALTHCARE INSURANCE FRAUD BASED ON COMPUTER APPLICATION

Budi Santoso, Julita Hendrartini, Bambang Udji Djoko Rianto, Laksono Trisnantoro

Abstract


Background: The national healthcare insurance (JKN) has been in deficit since 2014-2016; one of the causes is fraud inpatient hospital service.

Objective: This study aimed to analyze the validity, reliability and effectiveness of detection system of national healthcare insurance fraud based on computer application in hospital.

Methods: Cross-sectional method was used. Fraud data were collected at one episode in the inpatient JKN participant service.

Results: Validity was assessed by Fischer exact test. The interpretation was done by hospital internal verification officer and BPJS Kesehatan verification officer. There were only 2 out of 1.106 services claims were different, resulted in p-value < 0.01. Reliability was assessed using Human Organization Technology Benefit questionnaire filled by admission administrator officer, BPJS Kesehatan officer and hospital internal verification officer; and then analyzed using Stata® software resulting in Cronbach’s alpha value of > 0.8. Effectiveness was assessed by reducing potential fraud, conducted by RSUP dr. Soeradji Tirtonegoro from May until July 2017, which on May 2018 there were 8 findings, June 1 finding, and on July 2018 had no finding.

Conclusion: System for detection of national healthcare insurance fraud based on computer application is valid, reliable and effective to be implemented in inpatient service in hospital.


Keywords


fraud detection, national healthcare insurance, computer application

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