Wibowo, Nugroho Mardi and Utari, Woro and Muhith, Abdul and Widiastuti, Yuyun (2019) Detection of Healthcare Fraud in The National Health Insurance Program Based on Cost Control. In: Proceedings of the International Conference on Tourism, Economics, Accounting, Management, and Social Science (TEAMS 19), 10-11 Oktober 2019, Bali.
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Abstract
Fraud in healthcare services has the potential toreduce the quality of health services, harming patients, and statefinances. However, the implementation of fraud prevention inhealthcare services has not been fully carried out. The purpose ofthis study is to determine the cost control-based fraud detectionalgorithm and detect potential healthcare services fraud inhospitals. The study was conducted at 4 hospitals in East Java -Indonesia. Data retrieval is done by the method of documentationand interviews. With interactive analysis generated, 10 costcontrol-based algorithms that can be used to detect fraudpotential in the hospitals. Based on the time series linearregression analysis, the results show that the data groups that canshow the fraud potential in the sample hospitals are (i) outpatient cases with special procedures; (ii) inpatient cases with speciadrugs; (iii) outpatient cases with special drugs; and (iv) inpatientcases with special prosthesis. Data groups that have not beenproven to have the fraud potential are (i) a comparison of thenumber of JKN inpatients with the number of bills of INA-CBGsinpatients; (ii) comparison of the number of JKN outpatients with the number of bills of outpatient INA-CBGs; (iii) diseaseseverity level; (iv) Inpatient cases bills to BPJS Health; (v)Outpatient case bills to BPJS Health; and (vi) inpatient cases with special procedures.
| Item Type: | Conference or Workshop Item (Paper) |
|---|---|
| Uncontrolled Keywords: | Fraud; Healthcare; Hospital, Cost Control |
| Subjects: | R Medicine > RA Public aspects of medicine |
| Divisions: | Faculty of Nursing and Midwifery > Program Study of Nursing Bachelor |
| Depositing User: | Mr. . Bagas |
| Date Deposited: | 26 Jun 2020 17:21 |
| Last Modified: | 22 Mar 2021 03:21 |
| URI: | http://repository.unusa.ac.id/id/eprint/6187 |
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