FRAUD DETECTION IN INDONESIA NATIONAL HEALTH INSURANCE IMPLEMENTATION: A PHENOMENOLOGY EXPERIENCE FROM HOSPITAL
Abstract
National Health Insurance (NHI) is one of policy that being implemented in many countries in the world in order to gain Universal Health Coverage (UHC). In Indonesia, National Health Insurance or known as Jaminan Kesehatan National (JKN) is performed by Badan Penyelenggara Jaminan Sosial (BPJS). Despite the new policy aim to protect people from unpredictable condition that threaten in health, it also brings a challenge. Implementation of NHI in Indonesia with INA-case based group’s prospective system payment that involves BPJS as insurance agency, hospital as a health care provider, and the patient as a customer led to fraud and moral hazard condition. The fraud and moral hazard condition caused the BPJS deficit financing in the first year of implementation in 2014. The objective of this study is to detecting fraud that occurs in hospital on implementing NHI. This was a qualitative research with phenomenology-interpretive approach. Data was collected through Interview with manager of BPJS, Internal Stakeholder of the hospital, and BPJS Patient. This study was conducted in one of private hospital in Indonesia in Mei-August
2015. This study suggested that fraud and moral hazard could occur in BPJS-provider relationship as well as in provider-patient while delivering health care. Government must improve the policy by strengthening the controlling and evaluation function in National Health Insurance Implementation. Considering of the important of case-mix team suggested as the way to reduce fraud and moral hazard in this concern.
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