EFFORTS TO PREVENT FRAUD IN IMPLEMENTATION OF JKN (NATIONAL HEALTH GUARANTEE)
Ida Sugiarti, Imas Masturoh, Fery Fadly

Politeknik Kesehatan Kementerian Kesehatan Tasikmalaya

Abstract

The implementation of the health insurance program (JKN) in the national social security system found various problems. One of them is the potential for fraud, which could cause harm to the national social security fund. Fraud is an act that is done intentionally by participants and health workers who are not following the regulations set by the government. The government has issued regulations relating to preventing fraud in the JKN system. Upcoding is one of the incidents of fraud in JKN. The establishment of a unit of officers in preventing fraud has been written in the Joint Decree on the Joint Team for JKN Fraud Handling. This study aims to see how hospital management to prevent fraud. The method used in this research is to use a qualitative method using open-ended question instruments that have been formed to obtain as much detailed information as possible. The results of this study found that the prevention team of JKN Fraud was formed at the hospital. Unfortunately, it has not been able to work optimally due to the absence of clear rules about carrying out the task. The incidence of fraud in hospitals is due to inaccurate coding, which is one of the causes, including the difference between diagnoses based on ICD10 and codes for the benefit of claims that refer to BPJS regulations. It also caused by a lack of supporting data in determining the diagnosis. So the need for policies from the hospital management to plan measures to prevent fraud by involving all essential elements, optimizing the role of the team, and coaching employees.

Keywords: Fraud, Claims, Hospital, JKN

Topic: Health, Medical, Pharmacy and Technology