马卡萨市大地地区医院基于输入和流程的欺诈潜在控制分析

Q3 Pharmacology, Toxicology and Pharmaceutics
Muhammad Alwy Arifin, A. As, Darmawansyah Amran Razak, M. Abadi, Muhammad Al- Fajrin
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引用次数: 0

摘要

欺诈(舞弊)行为造成巨大损失的风险要求政府发布关于预防和处理欺诈(舞弊)行为以及对医疗保险计划实施过程中的欺诈(舞弊)行为进行行政处罚的2019年第16号令(Permenkes No.16)。只是,在其实施过程中,仍存在一些与健康 BPJS 服务效率低下有关的问题,而这些问题最终表明了欺诈行为的发生。因此,需要努力防止欺诈行为的发生。本研究旨在探讨马卡萨市大地地区特殊医院(RSKD)欺诈控制的投入和过程。本研究采用描述性分析的定性方法,通过有目的的抽样选择信息提供者。本研究从国家医疗保险实施过程中的投入要素和过程要素两方面进行分析。研究结果表明,投入要素包括政策、人员和设施。过程部分包括潜在欺诈的驱动因素和抑制因素。导致潜在欺诈的因素包括核查人员和负责病人的医生对诊断的理解不同、缺乏关于预防欺诈的宣传以及缺乏一个联合医疗保险反欺诈小组。抑制潜在欺诈的因素包括标准操作的实施、道德规范、相关各方之间的协调、临床路径和 SPI 团队(内部监管团队)的监督。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Analysis of Fraud Potential Control Based on Input and Process in Dadi Regional Hospital, Makassar City
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).
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来源期刊
Pharmacognosy Journal
Pharmacognosy Journal Pharmacology, Toxicology and Pharmaceutics-Pharmacology
CiteScore
2.20
自引率
0.00%
发文量
151
期刊介绍: In 2004, as the PHCOG.NET – a non-profit private organization dedicated to Natural Products Research leading to develop promising drugs. Our main mission is to make information on herbal drug research readily available in different formats to suit the individual needs. Pharmacognosy Journal (Phcog J.) is one of the six journals published by Phcog.Net, Each issue covers different topics in natural product drug discovery, and also publishes manuscripts that describe pharmacognostic investigations, evaluation reports, methods, techniques and applications of all forms of medicinal plant research
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