Analysis of Fraud Provider Prevention of National Health Insurance: Case Study of Lasinrang Hospital, Pinrang Regency

Abstract

Since the entry into force of the National Health Insurance (JKN) in Indonesia, the potential for fraud in services has increased due to pressure from the new financing system, opportunities for lack of supervision, and there is justification for fraud. The purpose of this study was to analyze the implementation of the Republic of Indonesia's Minister of Health Regulation No. 16 of 2019 in the implementation of fraud prevention programs in Lasinrang Pinrang District Hospital. This study uses a qualitative method with a phenomenological design to explore the experience and awareness of the research subjects in this case BPJS verifiers, coders, clinicians, and hospital management. The results showed that the national health insurance fraud prevention system was in accordance with what was implemented in Lasinrang Pinrang General Hospital where the prevention system was in the form of policy and guidelines compilation, the culture of cheating prevention, team formation as well as quality control and cost control based on Permenkes No. 36 of 215, researchers also found obstacles faced in preventing fraud, namely the lack of attention to the Clinical Pathway as a reference for doctors to diagnose and determine the type of action in patients at Lasinrang Pinrang District Hospital. It is necessary to revise the formulation of policies and guidelines that refer to Permenkes no. 16 in 2019 because in this case the Lasinrang Pinrang Regional Hospital is still guided by Permenkes no. 36 of 2015 in carrying out efforts to prevent fraud (fraud) national health insurance.