79,000 Potentially Fraudulent Health Insurance Claims Found

Name: 79,000 Potentially Fraudulent Health Insurance Claims Found
Uploaded: 2018-11-13T08:07:21Z
Duration: 20 min 32 s
Description: Low healthcare costs are believed to have caused alleged fraud in hospitals’ health insurance claims. Controlling the National Health Insurance-Healthy Indonesia Card (JKN-KIS) program’s healthcare costs is critical to ensuring the program’s sustainability.

Low healthcare costs are believed to have caused alleged fraud in hospitals’ health insurance claims. Controlling the National Health Insurance-Healthy Indonesia Card (JKN-KIS) program’s healthcare costs is critical to ensuring the program’s sustainability.

· 3 minutes read

JAKARTA, KOMPAS – Low healthcare costs are believed to have caused alleged fraud in hospitals’ health insurance claims.

Controlling the National Health Insurance-Healthy Indonesia Card (JKN-KIS) program’s healthcare costs is critical to ensuring the program’s sustainability. Stricter controls should be implemented to uncover potentially inaccurate health insurance claims.

The Healthcare and Social Security Agency’s (BPJS Kesehatan) 2017 data showed recorded 79,000 potentially inaccurate health insurance claims totaling more than Rp 48 billion (US$3.24 million).

Indonesian Doctors Association (IDI) deputy chair Adib Khumaidi said on Monday (11/12/2018) in Jakarta that these potentially inaccurate claims were inseparable from insufficient JKN-KIS financing. Lacking inadequate budgets, hospitals may be forced to adjust the healthcare costs in what may amount as fraud – ethical, disciplinary and maybe even legal violations. “The condition hospitals are facing right now with regard to the financing system is difficult,” said Adib.

BPJS Kesehatan health insurance director Maya Amiarny Rusady said that the potentially inaccurate claims were detected through the Fraud Detection on Claim Data Analysis (Defrada) application. Not all inaccurate claims may be fraudulent. More evidence was required to ascertain whether an inaccurate claim was fraudulent or not.

In most inaccurate claims, the billed amount was higher than the actual listed cost for the medical procedure. “This may be caused by the staff’s miscomprehension of the coding system,” said Maya.

However, if an actual fraud were found, meetings would be held to decide upon the proper punitive measure.

UHC commitment

In the National Healthcare Roadmap, the government targets achieving Universal Health Coverage (UHC) by 2019. Non-optimal services for insurance subscribers, including inadequate financing with widespread implications, must be addressed to achieve UHC.

Adib said that the country would not be ready to realize UHC by next year. “It will be too early to declare that we have achieved UHC only in terms of participation. We need reviews to fix outstanding problems,” he said.

The key problem of the JKN-KIS lies in non-streamlined regulations between stakeholders. For example, the BPJS Kesehatan policies do not accommodate extensions to doctors’ medical licenses (SIP) in their system. Differing regulations on emergency procedures also exist at BPJS Kesehatan and the Health Ministry.

Another problematic aspect is the substandard services for subscribers, which is closely linked to the lack of funding. This funding shortage has widespread implications, including late claims payments to hospitals and claims payments that do not follow procedure.

The East Java head of the Indonesian Hospitals Association, Dodo Anondo, said that hospitals generally fulfilled payments to drug and medical equipment suppliers every two months. However, BPJS Kesehatan’s claims payments to hospitals were less frequent. Consequently, the hospitals’ cash flow was often disrupted.

Because of the late payments, the West Java administration is currently trying to find more funding sources to cover hospitals’ operational expenses and to maintain its patient services.

Indonesian Healthcare Economists Association chair Hasbullah Thabrany said that the government’s commitment to achieving UHC was reflected in the healthcare budget allocation, which affects subscribers’ out-of-pocket (OOP) costs, also known as household healthcare spending.

The healthcare budget has never exceeded 5 percent of gross domestic product (GDP), while household healthcare spending covers 47 percent of all healthcare costs.

National Social Security Council (DJSN) member Zainal Abidin said that standardizing healthcare services was among the most urgent JKN-KIS issues to be addressed.

Editor:

national health insurance