Fraud in healthcare facilities: A Narrative Review
PDF

Keywords

fraud
healthcare
universal health insurance
delivery of health care
health facilities

How to Cite

Mauren Michaela, S., Nurmalasari, M., & Hosizah, H. (2021). Fraud in healthcare facilities: A Narrative Review. Public Health of Indonesia, 7(4), 166–171. https://doi.org/10.36685/phi.v7i4.465

Abstract

Every country needs to develop Universal Health Coverage (UHC) to promote optimal levels of public health. But in realizing UHC, there must be some problems, one of which is fraud. Based on the Corruption Eradication Commission (KPK) data, potential fraud is detected from 175,774 claims of Advanced Referral Health Facilities (FKRTL) or worth Rp. 440 billion until June 2015. This review article describes the incidence of fraud in health care facilities. Out of a total of 12,736 cases of fraud, readmission occupies the most cases of fraud, which is 4,827 cases or 37.9%.
https://doi.org/10.36685/phi.v7i4.465
PDF

References

Adisasmito, W. (2016). Analisis pengaruh dimensi fraud triangle dalam kebijakan pencegahan fraud terhadap program jaminan kesehatan nasional di RSUP nasional cipto mangunkusumo. Jurnal Ekonomi Kesehatan Indonesia, 1(2). https://doi.org/10.7454/eki.v1i2.1871

Agiwahyuanto, F. (2019). Tinjauan tarif Ina-Cbgs pada pasien kasus infark miokard akut di RSUD KRMT Wongsonegoro Kota Semarang bulan Januari–Juni tahun 2018. Afiasi: Jurnal Kesehatan Masyarakat, 4(3), 76-82. https://doi.org/10.14710/jmki.v4i2.13594

Atmiroseva, A., & Nurwahyuni, A. (2017). Inpatient readmission insidence of national health insurance patients at partner hospitals of BPJS-Health in Sukabumi 2015. Journal of Indonesian Health Policy and Administration, 2(2), 20-24. https://doi.org/10.7454/ihpa.v2i2.1909

Bastani, H., Goh, J., & Bayati, M. (2019). Evidence of upcoding in pay-for-performance programs. Management Science, 65(3), 1042-1060. https://doi.org/10.1287/mnsc.2017.2996

Clark, S. L., Miller, D. D., Belfort, M. A., Dildy, G. A., Frye, D. K., & Meyers, J. A. (2009). Neonatal and maternal outcomes associated with elective term delivery. American Journal of Obstetrics and Gynecology, 200(2), 156. e151-156. e154. https://doi.org/10.1016/j.ajog.2008.08.068

Davies, S. L., & Jost, T. S. (1996). Managed care: Placebo or wonder drug for health care fraud and abuse. Georgia Law Review, 31, 373.

Djasri, H., Rahma, P. A., & Hasri, E. T. (2016). Korupsi dalam pelayanan kesehatan di era jaminan kesehatan nasional: Kajian besarnya potensi dan sistem pengendalian fraud. Integritas: Jurnal Antikorupsi, 2(1), 113-133.

Dua, P., & Bais, S. (2014). Supervised learning methods for fraud detection in healthcare insurance Machine Learning in Healthcare Informatics (pp. 261-285). Berlin: Springer.

Fathurrohman, N., & Dewi, A. (2018). Potential fraud in the primary healthcare. Jurnal Medicoeticolegal dan Manajemen Rumah Sakit, 7(3), 196-204. https://doi.org/10.18196/jmmr.7373

GroíŸ, M., Jürges, H., & Wiesen, D. (2021). The effects of audits and fines on upcoding in neonatology. Health economics, 30(8), 1978-1986. https://doi.org/10.1002/hec.4272

Hartati, T. S. (2016). Pencegahan kecurangan (Fraud) dalam pelaksanaan program jaminan kesehatan pada Sistem Jaminan Sosial Kesehatan (SJSN) (Studi di Rumah Sakit Umum Daerah Menggala Tulang Bawang). FIAT JUSTISIA: Jurnal Ilmu Hukum, 10(4), 715-732. https://doi.org/10.25041/fiatjustisia.v10no4.808

Hennig Schmidt, H., Jürges, H., & Wiesen, D. (2019). Dishonesty in health care practice: A behavioral experiment on upcoding in neonatology. Health Economics, 28(3), 319-338. https://doi.org/10.1002/hec.3842

Jou, S., & Hebenton, B. (2007). Insurance fraud in Taiwan: Reflections on regulatory effort and criminological complexity. International Journal of the Sociology of Law, 35(3), 127-142. https://doi.org/10.1016/j.ijsl.2007.04.002

Kementerian Kesehatan Republik Indonesia. (2015). Peraturan Menteri Kesehatan Republik Indonesia Nomor 36 Tahun 2015 Tentang Pencegahan Kecurangan (Fraud) Dalam Pelaksanaan Program Jaminan Kesehatan Pada Sistem Jaminan Sosial Nasional. Jakarta: Kementerian Kesehatan Republik Indonesia.

Kusumawati, A. N., & Pujiyanto, P. (2020). Analisis kinerja dokter verifikator internal dalam menurunkan angka klaim pending di RSUD Koja Tahun 2018. Jurnal Administrasi Rumah Sakit Indonesia, 6(1). http://dx.doi.org/10.7454/arsi.v6i1.3244

Lüngen, M., & Lauterbach, K. W. (2000). Upcoding--a risk for the use of diagnosis-related groups. Deutsche Medizinische Wochenschrift (1946), 125(28-29), 852-856. http://10.1055/s-2000-7019

Machmud, R., Syafrawati, S., Aljunid, S. M., & Semiarty, R. (2020). Does moral hazard occour in the implementation of social health insurance? Evidence from public hospitals in a rural province of Indonesia. Asia Pacific Fraud Journal, 5(1), 24-32. https://doi.org/10.21532/apfjournal.v5i1.133

Mahaputra, L. H. Fraud development in the national health guarantee system reviewed from criminal law aspects. International Journal of Law, 1(2), 13–21

Maidin, Z., & Palutturi, S. (2015). Fraud prevention in implementation in national health insurance Kendari City, Indonesia. International Journal of Health and Medical Sciences, 1(1), 17-21. https://doi.org/10.20469/ijhms.30003

Mitriza, A., & Akbar, A. (2019). Analisis pengendalian potensi fraud di Rumah Sakit Umum Daerah Achmad Moechtar Bukittinggi. Jurnal Kesehatan Andalas, 8(3), 493-499. https://doi.org/10.25077/jka.v8i3.1032

NHCAA. (2007). Health care fraud–a serious and costly reality for all Americans. Retrived from https://docplayer.net/15383485-Health-care-fraud-a-serious-and-costly-reality-for-all-americans.html

Niu, Q., Peng, Q., & ElMekkawy, T. Y. (2013). Improvement in the operating room efficiency using Tabu search in simulation. Business Process Management Journal. https://doi.org/10.1108/BPMJ-Nov-2011-0081

Nurfarida, I. (2014). Pengaruh potensi fraud dalam penerapan sistem jaminan kesehatan nasional terhadap mutu layanan di RSJ dr. Radjiman Wediodiningrat Lawang, Malang. https://doi.org/10.22146/jkki.36385

Palutturi, S., Makkurade, S., Ahri, R., & Putri, A. (2019). Potential for fraud of health service claims to BPJS health at Tenriawaru Public Hospital, Bone Regency, Indonesia. International Journal of Innovation, Creativity and Change, 8(5), 70-90.

Rizka, Z., Jati, S. P., & Syamsulhuda, B. (2018). Analisis pelaksanaan program pencegahan kecurangan (FRAUD) Jaminan Kesehatan Nasional di Puskesmas Kota Semarang. Jurnal Kesehatan Masyarakat (e-Journal), 6(4), 95-104.

Rosyida, I. A. (2018). Implementasi pengendalian internal pada pencegahan dan pendeteksian fraud rumah sakit di Bojonegoro. Jurnal Ekonomi Universitas Kediri, 3(1), 47-62.

Samsulhadi, A., & Chalidyanto, D. (2020). Factors affecting potential overpayment claim of government health insurance in naval hospital. EurAsian Journal of BioSciences, 14(2), 2651-2656.

Santoso, B., Hendrartini, J., Rianto, B. U. D., & Trisnantoro, L. . (2018). System for detection of national healthcare insurance fraud based on computer application, Public Health of Indonesia, 4(2), 46-56. https://doi.org/10.36685/phi.v4i2.199

Setyawan, F. E. B. (2015). Sistem pembiayaan kesehatan. Saintika Medika, 11(2), 119-126.

Shahriari, H., Belli, P., & Lewis, M. (2001). Institutional issues in informal health payments in Poland. World Bank Draft Report. https://openknowledge.worldbank.org/handle/10986/13679

Smit, D., & Derksen, J. (2020). The complexity of healthcare fraud-ethical and practical considerations. ethic@-An international Journal for Moral Philosophy, 19(2), 367-385. https://doi.org/10.5007/1677-2954.2020v19n2p367

Sommersguter-Reichmann, M., Wild, C., Stepan, A., Reichmann, G., & Fried, A. (2018). Individual and institutional corruption in European and US healthcare: Overview and link of various corruption typologies. Applied Health Economics and Health Policy, 16(3), 289-302. https://doi.org/10.1007/s40258-018-0386-6

Souza, J., Pimenta, D., Caballero, I., & Freitas, A. (2020). Measuring data credibility and medical coding: A case study using a nationwide Portuguese inpatient database. Software Quality Journal, 28(3), 1043-1061. https://doi.org/10.1007/s11219-020-09504-3

Sukma, D. P., Sulistiyono, A., & Novianto, W. T. (2018). Fraud in Healthcare Service. Paper presented at the SHS Web of Conferences.

Suryandari, E. S. D. H. (2019). Relationship between specificity and precision in writing the main diagnosis and accuracy of main diagnosis codes with financing claims in cases of DM in Dr Radjiman Wediodiningrat Hospital, Lawang. Modern Health Science, 2(2), p26-p26. https://doi.org/10.30560/mhs.v2n2p26

Syafrawati, S., Machmud, R., Aljunid, S. M., & Semiarty, R. (2020). Incidence and root cause of upcoding in the implementation of social health insurance in rural province hospital in Indonesia. Asia Pacific Fraud Journal, 5(1), 56-61. https://doi.org/10.21532/apfjournal.v5i1.135

Taslim, T., Arifin, M. A., Mallongi, A., Indar, I., Darmawansyah, D., & Russeng, S. S. (2020). Analysis of fraud provider prevention of national health insurance: Case study of Lasinrang Hospital, Pinrang Regency. International Journal of Progressive Sciences and Technologies, 21(2), 201-206. https://doi.org/10.25041/fiatjustisia.v10no4.808

Thompson, A. N., Cohen-Mekelburg, S., Udow-Philllips, M., Good, C. B., & Waljee, A. K. (2021). Dissecting drug pricing in gastroenterology and hepatology. Clinical Gastroenterology and Hepatology, 19(1), 10-13. e11. https://doi.org/10.1016/j.cgh.2020.07.057

Yuniati, D. I. (2017). Analisis hasil koding yang dihasilkan oleh coder di Rumah Sakit Pemerintah X di Kota Semarang tahun 2012. Jurnal Ekonomi Kesehatan Indonesia, 1(4). https://doi.org/10.7454/eki.v1i4.1791

Zafirah, S., Amrizal, M., Sharifah, E., & Aljunid, S. M. (2017). Incidence of clinical coding errors and implications on casemix reimbursement in a teaching hospital in Malaysia. Malaysian Journal of Public Health Medicine, 17(2), 19-28.

Zafirah, S., Nur, A. M., Puteh, S. E. W., & Aljunid, S. M. (2018). Potential loss of revenue due to errors in clinical coding during the implementation of the Malaysia diagnosis related group (MY-DRG®) Casemix system in a teaching hospital in Malaysia. BMC Health Services Research, 18(1), 1-11. https://doi.org/10.1186/s12913-018-2843-1

Authors who publish with Public Health of Indonesia agree to the following terms:

  1. Authors retain copyright licensed under a Creative Commons Attribution-NonCommercial CC BY-NC 4.0, which allows others to remix, tweak, and build upon the authors' work non-commercially, and although the others' new works must also acknowledge the authors and be non-commercial, they don't have to license their derivative works on the same terms.
  2. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access). Authors can archive pre-print and post-print or publisher's version/PDF.

Downloads

Download data is not yet available.