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), November 2019.
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Abstract
Fraud in healthcare services has the potential to reduce the quality of health services, harming patients, and state finances. However, the implementation of fraud prevention in healthcare services has not been fully carried out. The purpose of this study is to determine the cost control-based fraud detection algorithm and detect potential healthcare services fraud in hospitals. The study was conducted at 4 hospitals in East Java - Indonesia. Data retrieval is done by the method of documentation and interviews. With interactive analysis generated, 10 cost control-based algorithms that can be used to detect fraud potential in the hospitals. Based on the time series linear regression analysis, the results show that the data groups that can show the fraud potential in the sample hospitals are (i) outpatient cases with special procedures; (ii) inpatient cases with special drugs; (iii) outpatient cases with special drugs; and (iv) inpatient cases with special prosthesis. Data groups that have not been proven to have the fraud potential are (i) a comparison of the number of JKN inpatients with the number of bills of INA-CBGs inpatients; (ii) comparison of the number of JKN outpatients with the number of bills of outpatient INA-CBGs; (iii) disease severity 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: | H Social Sciences > HC Economic History and Conditions |
| Divisions: | Prosiding |
| Depositing User: | Mochamad Danny Rochman, A.Md. Lib., S.S.I. |
| Date Deposited: | 28 Apr 2021 08:40 |
| Last Modified: | 20 Dec 2022 08:39 |
| URI: | http://eprints.uwp.ac.id/id/eprint/2698 |
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