Public Health of Indonesia Santoso.
, et al.
Public Health of Indonesia.
2018 June.
:46-56
http://stikbar.
org/ycabpublisher/index.
php/PHI/index ISSN: 2477-1570
Original Research
SYSTEM FOR DETECTION OF NATIONAL HEALTHCARE INSURANCE FRAUD BASED
ON COMPUTER APPLICATION
Budi Santoso*.
Julita Hendrartini.
Bambang Udji Djoko Rianto.
Laksono Trisnantoro Medical Faculty of Universitas Gadjah Mada Accepted: 1 June 2018 *Correspondence:
Budi Santoso Medical Faculty of Universitas Gadjah Mada Farmako St.
Sekip Utara Yogyakarta 55821 Phone/Fax: .
545458 E-mail: busan_ent@yahoo.
Copyright: A the author.
YCAB publisher and Public Health of Indonesia.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: The national healthcare insurance (JKN) has been in deficit since 2014-2016.
one of the causes is fraud inpatient hospital service.
Objective: This study aimed to analyze the validity, reliability and effectiveness of detection system of national healthcare insurance fraud based on computer application in hospital.
Methods: Cross-sectional method was used.
Fraud data were collected at one episode in the inpatient JKN participant Results: Validity was assessed by Fischer exact test.
The interpretation was done by hospital internal verification officer and BPJS Kesehatan verification officer.
There were only 2 out of 1.
106 services claims were different, resulted in p-value < 0.
Reliability was assessed using Human Organization Technology Benefit questionnaire filled by admission administrator officer.
BPJS Kesehatan officer and hospital internal verification officer.
and then analyzed using StataA software resulting in CronbachAos alpha value of > 0.
Effectiveness was assessed by reducing potential fraud, conducted by RSUP dr.
Soeradji Tirtonegoro from May until July 2017, which on May 2018 there were 8 findings.
June 1 finding, and on July 2018 had no finding.
Conclusion: System for detection of national healthcare insurance fraud based on computer application is valid, reliable and effective to be implemented in inpatient service in hospital.
Keywords: fraud detection, national healthcare insurance, computer application INTRODUCTION The National Health Insurance Program (JKN) as the embodiment of the National Social Security System (SJSN) has been implemented since January 1, 2014.
After implementation of National Health Insurance, there has always been a deficit in the year of 2014, 2015, 2016, and 2017, i.
there was negative balance between the income of BPJS Kesehatan from patientsAo premium and the amount of money that BPJS Kesehatan had to pay to first level health facility and Indonesia Case Base Group (INA-CBGAo.
claims in advanced referral health facility (FKRTL)/hospital.
One of the causes was JKN fraud inpatient JKN participant hospital service (Cahyono, 2015.
Hartati, 2016.
Tariden, 2.
JKN Fraud is intentional dishonest or unfair action to obtain claims that is larger than normal for fraudulent and financial loss for Public Health of Indonesia.
Volume 4.
Issue 2.
April-June 2018 others in the National Health Insurance Program (JKN) service (Ariati, 2.
JKN
fraud is a white-collar crime, which one of the causes is the difference between INA-CBG's tariff rates based on the severity of diagnosis or Fraudulent healthcare is contagious if the Ministry of Health, as regulator, or BPJS Kesehatan, as executor of the guarantee, does not act.
Healthcare facility that commit undetected JKN fraud and unpenalized would be an example to other healthcare facilities.
Without prevention and penalizing action.
BPJS Kesehatan financial losses will continue to grow (Ariati, 2015.
Hendrartini, 2014.
Honer, 2015.
Sutoto, 2014.
Trisnantoro, 2.
JKN fraud could be conducted by participants of National Health Insurance.
BPJS Kesehatan, advanced referral health facilities (FKRTL), drugs and medical devices providers (Busch.
MOH, 2.
Program (JKN) within National Social Security System (SJSN), as a legal basis for the development of JKN's anti-fraud system in healthcare services in Indonesia.
Since its launch in April 2015, the regulation has been implemented ineffectively, which causes fraudulent impact on healthcare services and potentially increases fraud case, and yet there was no sufficient fraud control system.
Healthcare providers are in the spotlight in healthcare fraud prosecution, as worldwide research shows that 60% of healthcare fraudulence comes from healthcare providers (Fadjriadinur, 2.
In early 2017, the Corruption Eradication Commission (KPK) reported 1 million claims with potential JKN fraud, hence currently KPK is trying to build a JKN fraud prevention, detection and management system which involve all JKN stakeholder executives such as Ministry of Health.
BPJS Kesehatan, healthcare facilities, medicine and medical device providers (Suparman, 2.
The purpose of this study was to assess the validity, reliability and effectiveness of prevention and early detection system of national healthcare insurance fraud based on computer application that contains fraud indicators based on Permenkes No.
36 Year 2015 on fraud prevention in National Health Insurance Program (JKN).
We conducted this study at RSUP dr.
Soeradji Tirtonegoro Klaten as the advanced referral health facility (FKRTL).
Fraud prevention in healthcare services had been done by stakeholders of National Health Insurance services as the following: .
The government as regulator has taken precautions by establishing fraud indicator, service standards and medical devices that can be used in all healthcare services.
The Government, together with BPJS Kesehatan, would monitor and evaluate the implementation of the National Health Insurance in relation to the potential fraud.
Routine investigations by insurance companies on claims filed by Healthcare providers/hospital facilities filed claims in accordance to services provided to National Health Insurance participants, providing standardized services and benefits such as fulfilling the right of participants, hospitals conduct internal verification by Internal Supervisory Unit (SPI).
Insurance participants provide their identity so as not to be abused by unauthorized parties, requesting information pertaining to services provided by healthcare providers (Jasri, 2.
METHODS
Study Design The research method used was cross sectional (Creswell & Creswell, 2.
Potential fraud was conducted by administration officer.
BPJS Kesehatan officer and internal hospital verification officer that were taken in one episode in inpatient JKN participant service, which started from registration until claim submission to BPJS Kesehatan.
The amount of potential loss caused by JKN fraud prompted the government to issue Permenkes No.
36 Year 2015 on fraud prevention in National Health Insurance Population and Sample of this Study Population is inpatient JNK participants.
Sample of this study were as follows: .
Public Health of Indonesia.
Volume 4.
Issue 2.
April - June 2018 Inpatient JKN participant, .
BPJS Kesehatan officer, and .
hospital internal verification application (Figure .
containing fraud indicators (Table .
The Kappa test questionnaire to test for the agreement on fraud TURP officers.
BPJS Kesehatan officers and internal verification officers filled questionnaires in two different times, with one week interval.
Hot-fit questionnaire to assess the reliability of prevention and early detection system for potential fraud.
Research Material Research materials consisted of: .
Informed consent, for patient/family approval, admission officer (TURP).
BPJS Kesehatan officer and hospital internal verification officer willing to be involved in the research.
Computer Figure 1 Dashboard of computer application Table 1 Fraud indicators in this study Perpetrator Inpatient JKN Participant BPJS Kesehatan Hospital Fraud Indicators Using fake National Health Insurance card Using another personAos National Health Insurance Using expired National Health Insurance card Fake referral letter Demanding uninsured service Negating the benefits that the participant is entitled Reducing the benefits that the participant is entitled Changing uninsured service into insured service Conducting downcoding Conducting bundling of service Conducting self-referral Conducting kickback Conducting readmission intentionally Conducting unnecessary treatment Conducting no medical value Conducting no standard of care Conducting over-utilization Conducting unbundling / fragmentation Conducting outpatients service into inpatients Public Health of Indonesia.
Volume 4.
Issue 2.
April - June 2018 Yes Manipulating length of stay into longer duration Manipulating date of service Conducting phantom visit Conducting phantom procedure Conducting cancelled service and still claim the Raising type of room charge Conducting up coding Conducting Diagnostic Related Group (DRG) creep Separating one diagnosis into more than 1 Adding symptoms from a diagnosis Conducting keystroke mistake Conducting error in determining main diagnosis Conducting error in determining main procedure Conducting cloning Conducting phantom billing Conducting inflated bills Conducting repeat billing Charging fee to the patients treated according to his classAo rights Conducting cream skimming Referring patient when INA-CBGAos claim is used Manipulating ventilator usage into longer duration Independent variable was the prevention and early detection system of fraud in JKN participantAos inpatient services.
Dependent effectiveness of prevention and early detection system of fraud in JKN participantAos inpatient perform a required function underspecified conditions for a certain period of time When a system fails to perform satisfactorily, repair is normally carried out to locate and correct the The system is restored to operational effectiveness by making an adjustment or by replacing a component.
Maintainability is defined as the probability that a failed system will be restored to specified conditions within a given period of time when maintenance is performed according to prescribed procedures and resources (Pham, 2.
Validity is often defined as the extent to which an instrument measures what it purports to measure, the instrument measure what it is intended to measure.
Validity requires that an instrument is reliable, but an instrument can be reliable without being valid (Eldridge, 2007.
Kimberlin & Winterstein, 2.
Reliability estimates are used to evaluate: .
the stability of measures administered at different times to the same individuals or using the same standard .
estAeretest reliabilit.
the equivalence of sets of items from the same test .
nternal consistenc.
or of different observers scoring a behavior or event using the same instrument .
nterrater reliabilit.
Reliability coefficients range from 0.
00 to 1.
00, with higher coefficients indicating higher levels of reliability (Kimberlin & Winterstein, 2.
The reliability of a product .
r syste.
can be defined as the probability that a product will Effectiveness of prevention and early detection system of national healthcare insurance fraud based on computer application depends on: .
Willingness of hospital director to implement anti-fraud system.
Socialization of fraud indicator to all hospital officers.
Acceptance of hospital officer to system and computer application that can simplify their task in prevention and early detection of fraud.
Competence of hospital officers to operate computer application.
Competence of hospital/BPJS Kesehatan officers to decide whether inpatient JKN participant service is a potential fraud or not.
Public Health of Indonesia.
Volume 4.
Issue 2.
April - June 2018 Data Analyses HOT-Fit research questionnaire (Human Organization Technology and Benefi.
table 2 filled by TURP officer.
BPJS Kesehatan officer and internal hospital verification We used StataA (Torres-Reyna, 2.
, software for HOT-Fit questionnaire test (Yusof.
Kuljis.
Papazafeiropoulou.
Stergioulas, 2.
, and the result was CronbachAos Alpha value (Tavakol & Dennick.
Validity was defined as decision whether the inpatient JKN participant service was fraudulent or not.
Validity was assessed by Fischer exact test of the interpretation of fraud indicator between hospital internal verificator and BPJS Kesehatan officer.
Reliability was defined the consistency of system using by user to prevent and detect a potential fraud.
Reliability was assessed using Table 2 HOT-Fit questionnaire to assess computer application implementation VARIABLES
System Quality Information Quality Service Quality System Usage
User
Satisfactions Organization System
Net-Benefit
CODE
INDICATORS
KS1
KS2
KS3
KS4
KS5
KS6
KS7
KI1
KI2
KI3
Computer application has usage manual Computer application is easy to be learned Computer application is easy to be applied Computer application has already been integrated Computer application is reliably operated Computer application has access rights Computer application is helpful to detect JKN fraud Computer application provides complete information on JKN fraud Computer application provide true information on JKN fraud Computer application provide information to understand JKN fraud Computer application provide timely information to detect JKN fraud Computer application generate the same information as the data input Researchers respond quickly when needed Researchers give quality and service assurance for users Researchers have caring characteristic .
when assisting Researchers work on the problems until completely solved Users use Computer application to detect JKN fraud
Users believe that computer application simplify detection of fraud
Users could accept Computer application usage manual well
Users used the Computer application easily Computer application helps to prevent JKN fraud
Computer application helps to detect JKN fraud
Researchers organize Computer application team well
Researchers manage Computer application well
Researchers could resolve conflicts between computer application Computer application facilitates detection of JKN fraud
Computer application makes JKN fraud detection more effective Computer application could reduce the level of JKN fraud
Computer application increases communication among working units on JKN fraud detection Computer application improve organizationAos performance on preventing JKN fraud
Computer application could improve organizationAos performance when facing demands if there are JKN frauds KI4
KI5
KL1
KL2
KL3
KL4
PS1
PS2
PS3
PS4
KP1
KP2
ST1
ST2
ST3
NB1
NB2
NB3
NB4
NB5
NB7
D: Denied N: No Comment A: Agree Effectiveness was defined as the system is effective to prevent and detect the fraud indicator and then must be avoided by patient.
ANSWER TYPES
VD D N A SA
BPJS Kesehatan or hospital.
The effectiveness was assessed by reducing of potential fraud conducted by inpatient JKN participant Public Health of Indonesia.
Volume 4.
Issue 2.
April - June 2018 hospital.
BPJS Kesehatan and hospital during May until July 2017.
93%).
Only 20% of the population agreed to be enrolled because: they had no time, they were in a hurry, especially emergency patient.
not interested in the research, etc.
9 of 9 .
%) admission administrator officers were interested in the research.
2 of 2 .
%) BPJS Kesehatan officers were interested in the .
20 of 20 .
%) internal hospital verification officers were interested in the RESULTS Distribution of research subject As shown in the table 3, research participants were as follows: .
Inpatients JKN participants by purposive sampling 1.
106 of 5.
Table 3 Distribution of research subject Research subject Inpatient JKN participant Admission administrator officer BPJS Kesehatan officer Internal hospital verification officer Total Sample Potential fraud based on fraud indicators Table 4 shows that there were 9 potential fraud cases in RSUP dr.
Soeradji Tirtonegoro from May-July 2017 classified as follows: .
Readmission: 4 .
44%).
Changes from uninsured into insured by JKN: 2 .
22%).
Keystroke .
11%).
Fragmentation/unbundling: 1 .
11%).
Cancelled service: 1 .
11%).
Readmission Population Percentage was the highest case in this study.
Because RSUP dr.
Soeradji is a regional referral hospital in Klaten and the cases admitted were rehospitalization in one month as limitation for readmission term was high.
There was no fraud by inpatient JKN participant or BPJS Kesehatan.
Table 4 Potential fraud based on fraud indicators (May-July 2.
by RSUP dr.
Soeradji Tirtonegoro JKN Fraud Indicators Readmission/unbundling Changes from uninsured into insured by JKN Keystroke mistake Fragmentation/unbundling Cancelled service TOTAL Validity of prevention and detection system Table 5 shows that Fischer exact test shows that only 2 out of 1.
106 service claims were interpreted differently between hospital internal verification officer and BPJS Kesehatan officer.
P value < 0.
001, data show Total Percentage that system for prevention and early detection of national healthcare insurance fraud based on computer application were valid to be implemented as anti-fraud system in the Table 5 Fischer exact test for validity based on service claim Potential fraud BPJS Kesehatan Officer No potential fraud Total Hospital internal verification officer Potential fraud No potential fraud Public Health of Indonesia.
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April - June 2018 Total Reliability of prevention and detection Reliability test as shown in the table 6 for prevention and early detection system of national healthcare insurance fraud based on computer application was done using HOT-Fit questionnaire and StataA software to obtain CronbachAos Alpha value with the following results: .
TURP officer score 0.
BPJS Kesehatan officer score 1.
Hospital internal verification officer score The data shows that prevention and early detection system of national healthcare insurance fraud based on computer application is reliable to be implemented as anti-fraud system in hospital.
Table 6 HOT-Fit test recapitulation Indicator TURP
System Quality Information Quality Services Quality System Utilization User Satisfaction Organization System
Net Benefit
BPJS
Kesehatan Hospital internal Effectiveness of prevention and early detection system
Table 7 Potential JKN fraud in May-July 2017
Month
Total
Percentage May 2017
June 2017
July 2017
TOTAL
Source: Credit Accomplishment I of RSUP dr.
Soeradji Tirtonegoro Table 7 shows that there were 9 potential fraud findings within May-July 2017: 8 cases in May .
88%), 1 case in June .
12%), and 0 .
%) in July.
Potential fraud in hospital was significantly reduced, therefore, prevention and early detection system of national healthcare insurance fraud based on computer application is effective to be implemented as anti-fraud system in hospital.
reliability and validity of the measures (Kimberlin & Winterstein, 2.
Validity is often defined as the extent to which an instrument measures what it purports to measure, the instrument measure what it is intended to measure.
Validity requires that an instrument is reliable, but an instrument can be reliable without being valid (Eldridge, 2007.
Kimberlin & Winterstein, 2.
In this study, the system measured what it was intended to measure such as potential fraud or not, although there were only 2 out of 1.
106 claims with different interpretation .
of fraud or not between BPJS Kesehatan and internal hospital verification officer, 1.
097 claims had the same interpretation .
of no potential DISCUSSION Tests or instruments that are valid and reliable to measure such constructs are crucial components of research quality.
Key indicators of the quality of a measuring instrument are the Public Health of Indonesia.
Volume 4.
Issue 2.
April - June 2018 fraud, and 7 claims with the interpretation .
of potential fraud.
internal regulation in the form of good governance of organization and clinical services .
Hospital can develop healthcare facilities oriented in quality and cost control by utilizing effective and efficient management, evidence-based information technology and formation of fraud prevention team in the .
Hospital can develop a fraud prevention behavior as part of organization management and clinical management oriented to quality control and cost control based on TARIK (Transparency.
Accountability.
Responsibility.
Independency.
Fairnes.
principle (Hartati, 2016.
Jasri, 2.
Reliability estimates are used to evaluate: .
the stability of measures administered at different times to the same individuals or using the same standard .
estAeretest reliabilit.
the equivalence of sets of items from the same test .
nternal consistenc.
or of different observers scoring a behavior or event using the same instrument .
nterrater reliabilit.
Reliability coefficients range from 0.
00 to 00, with higher coefficients indicating higher levels of reliability (Kimberlin & Winterstein.
The reliability of a product .
r syste.
can be defined as the probability that a product underspecified conditions for a certain period of time When a system fails to perform satisfactorily, repair is normally carried out to locate and correct the fault.
The system is restored to operational effectiveness by making an adjustment or by replacing a component.
Maintainability is defined as the probability that a failed system will be restored to specified conditions within a given period of time when maintenance is performed according to prescribed procedures and resources (Pham, 2.
Hospitals can prevent any potential fraud by forming fraud prevention team in the hospital that is responsible for: .
Creating director circular letter on fraud prohibition.
Early detection of fraud based on service claim data.
Socialization policy, regulations and new customs oriented on quality control and cost .
Improving coder, medical doctor and other officersAo capability regarding claims.
Taking precautions, detection and manage .
Monitoring and evaluation.
Establishing commitment between hospital and BPJS Kesehatan in case of overpayment, steps on how to cooperate, and in case of fraud suspicions, clarification should be made by the .
Internal verification by SPI before submitting the claim.
Developing clinical practice guideline and the clinical pathway for each diagnosis.
Reporting to hospital chief director every six months (Hartati, 2016.
Sutoto, 2.
Effectiveness of system for prevention and early detection of national healthcare insurance fraud based on computer application depends on: .
Willingness of hospital director to implement anti-fraud system.
Socialization of fraud indicators to all hospital officers.
Acceptance of hospital officers to apply the system and computer application that can simplify their task in prevention and early detection of fraud.
Competence of hospital officers to operate computer application.
Competence of hospital officers to decide whether a health service is potentially fraudulent or not.
In this study, there was a significant decrease in potential fraud from 8 findings in May to 1 finding June and no finding in July .
Hospitals should optimize fraud prevention team who would spearhead the development and implementation of fraud prevention and detection system.
Ministry of Health Regulation (Permenke.
No 36/2015 stated that this team should at least consist of internal examination unit element, medical committee, medical recorder, coder, and other related The teamAos task is conducting prevention and early detection for fraud based on claim data to BPJS Kesehatan, socializing regulations orienting on quality and cost control to support implementation of good organizational and clinical governance.
Fraud Development of fraud prevention system, as Permenkes No.
36, 2015 stated, must be done through three processes: .
Hospital formulates Public Health of Indonesia.
Volume 4.
Issue 2.
April - June 2018 prevention teamAos competence on fraud prevention and detection should also be improved (Hartati, 2016.
Jasri, 2.
rehabilitation hospitals or skilled nursing facilities where, in addition to rehabilitative services, they can receive around-the-clock medication management (Hubbard & McNeil.
Wier.
Barrett.
Steiner, & Jiang, 2.
In this study, most potential fraud event in National Health Insurance by hospital was readmission caused by: .
RSUP dr.
Soeradji Tirtonegoro as referral hospital in Klaten district, handled severe referral cases with a potency to relapse within less than one month after discharge.
Hospital staffs were not careful in detecting patients who were readmitted in less than 30 days after being discharged by the doctor, where the claim should be in the same episode as the previous Hospitals should pay more attention for potential fraud in readmission so that the same mistake would not be repeated again.
Barriers to implementation and successful outcomes: .
Incomplete and inaccurate patient medication lists: Hospital staff report many of the same difficulties faced by office-based physicians in assembling an accurate list of each patientAos prescription medications on a timely and cost-effective basis.
Limitations of family caregiver or other sources of patient support: For patients experiencing a decline in cognitive function, a family caregiver can be the de facto medication manager.
Difficulty scheduling timely follow-up visits for primary community-based .
Funding challenges: The new discharge planning and transitional care models represent intensive, high-touch patient care approaches that can be difficult to fund in the long term (Hubbard & McNeil, 2.
Studies on readmission event conducted in hospitals from various locations generate several data as follows: .
Readmission was the most frequent event in potential fraud, such as upcoding (Ardyanto, 2.
Medicare penalizes hospitals with higher than expected readmission rates by up to 3% of annual inpatient payments (Barnett.
Hsu, & McWilliams, 2.
Readmission event was 6% (Jencks.
Williams, & Coleman, 2009.
Toomey et al.
, 2.
nearly 30% of 30-day readmissions to a childrenAos hospital may be potentially preventable (Toomey et al.
, 2.
High risk of readmission could occur in: low education level, depression, physical inactivity, hypertension, diabetes, and Ou3 risky behaviors (Dupre et al.
, 2.
Potential fraud event in National Health Insurance which uninsured patients were changed into insured in this study occurred in:
healthy newborns who should be claimed together with the mothersAo claim, but were claimed separately.
administration error such as incomplete admission requirement after 3 days but was still submitted for claim (BPJS Kesehatan, 2.
Keystroke mistake could occur due to hospital staffsAo carelessness when inputting patientsAo entry data.
potential fraud cases in this study did not increase the hospitalAos claim amount and hence was not detrimental to BPJS KesehatanAos finance (Mardha, 2.
Readmission reduction program could be achieved by: .
Hospital staffs manage patients according to standard of quality.
Home visit service conducted soon after discharge.
Disease management: .
support the physician or practitioner/patient relationship and care .
evidence-based practice guidelines and patient empowerment and .
evaluate outcomes in an ongoing basis.
Post-acute care: many patients are not discharged directly from the hospital to the home, but instead go to longterm Fragmentation/unbundling were caused by submission of inpatient JKN participant claim together with outpatient claim.
there should only be one inpatient JKN participant claim submitted to BPJS Kesehatan (Dodaro, 2.
Canceled service happened because hospitals have treated patients in the emergency room and had spent resources during temporary treatment before referring patients to other hospitals because the hospital was unable to Public Health of Indonesia.
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April - June 2018 provide comprehensive patient care (Thorpe.
Deslich.
Sr, & Coustasse, 2.
Limitation of this study include: .
the success of prevention and early detection system implementation depend on capability of admission administrator, internal hospital verificator.
BPJS Kesehatan to decide whether there is fraud or not.
computer application was not bridging yet with information system of hospital or INA-CBGAos software to simplify implementation, the officer only need to input patientAos medical record number, not the entire patient identities were put into the fraud information system.
Fraud indicator in this study was still incomplete, further studies are needed to add new fraud indicators to complete fraud indicator.
study could be used as an addition to the existing fraud indicators stated in the Ministry of Health Regulation (Permenke.
No 36/2015.
CONCLUSION
REFERENCES