Including the development of health insurance in developing countries showed increasing public awareness and realize that the main solution is to obtain medical care through health insurance . But at the same time all parties are trying to benefit as much as possible in the process . Because of the desire to obtain these benefits then it is inevitable the occurrence of a desire to do something or act in accordance with the applicable provisions sebesarrbesarnya to gain benefits from the process . The act or thing was done especially after knowing celah2 that can be used in an attempt to make a profit from the process.
Experience of health insurance companies in the United States suggests that fraud and abuse in health insurance can reach 10 % of total health care costs each year . Fraud in Indonesia still can not be displayed because of the absence of some form of routine investigation of the claims submitted to the insurance company . This is a weakness that must be corrected ahead to find a solution to the possibility of fraud in Indonesia .
In the absence of known health insurance claims filed by participants individually insurance to insurance companies and other forms of filing a claim is conducted by the institution Giver Services
Health ( provider ) . Of course, these two forms of filing a claim is a possibility that even this is not happening fraud that may cause harm to the insurance company .
In the health insurance we recognize the existence of third parties , namely the interconnected participants as beneficiaries , health care providers (providers ) as those who provide services in accordance with the benefits that are entitled to insurance companies as participants and those who manage the financing of these benefits . In conjunction with the implementation of social insurance , especially health insurance , the government acts as regulator and has a very big role . The existence of such parties and linkage masing2 parties in relation to benefits and health insurance fraud will be described .
Fraud in health care is referred to as a form of deliberate efforts by creating a benefit that should not be enjoyed by individuals or institutions and can harm others . According to the National Haelth Care Anti - Fraud Association 's ( NHCAA ) states that " Health care fraud is an intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual , or the entity or to some other party . "
In health care fraud committed against hal2 or circumstances and situations related to the process of health care , health care coverage or benefits and financing .
In health care , also known known as other forms of abuse that can be detrimental to the health service . However, the term is more widely used in health insurance is defined as activities or actions that harm the health services but not included in the category of fraud . Abuse can be in the form of malpractice or overutilization .
By Heath Insurance Assosiciation of America ( HIAA ) , fraud in health care or health insurance can be categorized as follows :
Fraud by participants as consumers of health insurance
Fraud by health care providers (providers )
Fraud by insurance companies
Thus, the fraud can be carried out by the parties relating to health care that needs to be traced from any party who has made such fraud .
Fraud is usually done by the consumer or health insurance participants include:
Making untrue statements in the submission of claims
Making untrue statements in terms of eligibility to obtain health care or at the time of filing a claim .
Fraud by Health Care Providers (providers ) can be carried out either by individuals within the institution , such as physicians , nurses , etc. , or in the institution who knowingly commit fraud . Form of fraud by individuals is done deliberately to increase the incentives for those concerned . While fraud is carried out by the institution is carried out to improve the bill claim that means increasing the income of the institution .
The usual form of fraud carried out by Health Care Providers , among others :
Filing a claim with service or action list is not given, for example, laboratory tests were conducted on two types of examination but raised as 3 or more types of checks .
Manipulation of the diagnosis by raising the level of the type of measures such as appendiectomy appendiectomy charged with complications that require major surgery that billed the higher rate .
Falsifying the date and duration of the treatment . This usually occurs by adding the number of days of inpatient care by adding the date when the patient had come home .
Perform billing claims with a greater rate than they should , for example, bills of medical devices that are larger than the regular price .
Make a claim under the trade name drug when the drug is given by the generic name .
Based on the experience in the United States , the most frequent type of fraud committed by providers is falsifying diagnoses and dates of service that reaches 43 % of the cases . Besides that fraud is being done to improve the bill to make a claim against the bill were not given service reached 34 % .
In principle, the insurance business is a business that is based on trust. As for the trust among the participants are consumers of insurance or a doctor or health care provider ( provider ) so often the relationship between patient and doctor become asymetri relationship because the patient was very resigned to the doctor or the CO that determines all kinds of actions that will be given to participants . Trust between the participants of the insurance companies that the benefits that have been agreed will actually obtained insurance participants . It is often also cause imbalances because the insurance company that specifies all the provisions that must be followed by participants . Confidence is also among insurers to Health Care Providers in the hope that the service provided to satisfy the participants so that will positively impact both the giver and the Health Care insurance companies . With this basis , the actual fraud problem can be overcome if this trust is maintained between the three parties.
Because of this fraud is an activity or action that can give a huge impact in the financing of health care is necessary for efforts to prevent fraud .
Based on the experience of developed countries , fraud can be prevented , among others, through the role of all concerned Government :
Establish provisions of law or the law of fraud that includes about penalties that may be imposed to those who commit fraud .
Besides, the government needs to establish standards of care , standard therapy , standard drugs and medical devices that can be a reference for all health care measures . Thus, the fraud can be traced based on the provisions that have been defined .
Giver of Health Services ( the provider ) :
Care Giver health insurance companies to maintain confidence in the services provided and manifested in the form of filing claims In accordance with the service provided and accurate .
Health Care Giver maintain patient trust or insurance participants to provide services in accordance with a predetermined standar2 and benefits that should be the right of participants to either .
Participants insurance :
Completing the actual identity of the participants and do not provide opportunities for misuse by an unauthorized party .
Requesting information on the services provided by the Health Care Providers , physicians and nurses .
Insurance companies :
Perform routine investigation of the claims filed with the random cross-checking medical records .
Consult the Medical Advisory Soard ( MAS ) against claims filed or the type of action and therapy provided by the provider . Besides, MAS can act as a party providing a second opinion on the action that will be given to the patient's health care giver .
With advances in the development of health insurance in Indonesia, which has now reached 42 % of the total population possess the health insurance fraud and abuse kasus2 should be a common concern . Increased health care costs that occur only because due to fraud should be avoided . Therefore, the participation of all stakeholders is crucial to prevent and reduce the likelihood of fraud
