Analysis of Fraud Potential Control Based on Input and Process in Dadi Regional Hospital, Makassar City

Abstract

The risk of large losses arising from acts of fraud (fraud) requires the government to issue Permenkes No. 16 of 2019 concerning the prevention and handling of fraud (fraud) and the imposition of administrative sanctions against fraud (fraud) in the implementation of the health insurance program. It's just that in its implementation, there are still a number of problems related to the inefficiency of Health BPJS services which ultimately indicate the occurrence of fraud. For this reason, efforts to prevent fraud are needed. This study aims to look at the input and process of fraud control at the Dadi Regional Special Hospital (RSKD) Makassar City. This study uses a qualitative approach with descriptive analysis method by selecting informants by purposive sampling. This research is seen from the input components and process components in the implementation of the National Health Insurance. The research results show that input components include policies, personnel and facilities. The process component includes driving factors and inhibiting factors for potential fraud. Factors driving the potential for fraud are differences in understanding between the verifier and the doctor in charge of the patient regarding the diagnosis, the lack of outreach about fraud prevention and the absence of a JKN anti-fraud team. Factors inhibiting potential fraud are the Implementation of Standard Operations, code of ethics, coordination between parties involved, Clinical Pathway and supervision from the SPI team (Internal Supervisory Team).