Prevention of fraud in the implementation of the National Health Insurance (NHI) program (Case study: Abunawas Hospital Kendari City, 2023) Southeast Sulawesi Province, Indonesia, 2023
Authors: Lade Albar Kalza  , Rahman  , La Ode Ahmad Saktiansyah  , Esti Wulandari  , Miranda Tribuana Gita Astini  
Published: November 2023

Background: The World Health Organization (WHO) estimates that 7.29% of health funds are lost due to services proven to be fraudulent throughout the world. The National Health Care Anti-Fraud Association (NHCAA) estimates that health costs resulting from fraud are in the tens of billions of dollars. Fraudulent health insurance claims are carried out through service providers, insurance customers and insurance companies. The potential for fraud at the Abunawas Hospital, Kendari City, comes from the Patient Information and Complaints Providing (PICP) officer of the Kendari branch of BPJS, who stated that patients often complain that when they want to be admitted to the hospital, their class room is full, so patients are required to move up to class 1 level above, there is Also collecting fees from Social security administration agency patients purely related to procedures or medicines. This is suspected to be administrative manipulation on the part of the hospital. Based on this, potential fraud committed by hospitals risks harming state finances. Method: The type of research used is qualitative research, namely for see and describe how fraud is prevented in the JKN era at the Abunawas Regional Hospital, Kendari City. This research uses an explorative/exploratory approach. Determining informants was carried out using purposive sampling technique. The key informants in this research include the director of the Kendari City Regional Hospital while the regular informants are the INA CBGs Coder and the Social security administration agency verification officer. The data collection method was carried out using interviews. Data analysis used includes: data reduction, data presentation as well as drawing conclusions and verification. Result: The research results showed that the implementation of Minister of Health Regulation no. 16 of 2019 concerning Guidelines for preventing and handling fraud and the imposition of administrative sanctions against fraud in the implementation of the Health Insurance program at the Kendari City Regional Hospital involving elements of the Financial Audit Agency, Internal Supervisory Unit, Public Accounts Commission and Hospital Director as proxies budget users at the Kendari City Regional Hospital. Complaints or reports of alleged NHI fraud must at least consist of: the identity of the complainant, the name and address of the agency suspected of committing NHI fraud, and the reason for the complaint. If there is a dispute regarding determining whether there is NHI fraud or not, the Provincial Health Service or Health/City Service can forward the complaint to the NHI fraud prevention team appointed by the Minister of Health. Conclusion: Implementation of fraud prevention in NHI is carried out by the Minister, Head of the Provincial Health Service and Head of the Regency/City Health Service and Kendari City Regional Hospital in accordance with their respective authorities. Forms of guidance and supervision at the Kendari City Hospital include advocacy, outreach and technical guidance, training and increasing human resource capacity as well as monitoring and evaluation. Implementation of Minister of Health Regulation no. 16 of 2019 concerning Guidelines for preventing and handling fraud and the imposition of administrative sanctions against fraud in the implementation of the Health Insurance program at the Kendari City Regional Hospital involving elements of the Financial Audit Agency, Internal Supervisory Unit, Public Accounts Commission and Hospital Director as proxies budget users at the Kendari City Regional Hospital. So the hospital management collaborated with BPJS to form an anti-fraud investigation team in accordance with Minister of Health Regulation no. 16 of 2019 concerning guidelines and policies for preventing fraud and collaboration between integrity assessment surveys and public accounting firms in preventing fraud at Regional Hospital Kendari City.