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Journal : Asia Pacific Fraud Journal

DOES MORAL HAZARD OCCOUR IN THE IMPLEMENTATION OF SOCIAL HEALTH INSURANCE? EVIDENCE FROM PUBLIC HOSPITALS IN A RURAL PROVINCE OF INDONESIA Rizanda Machmud; Syafrawati Syafrawati; Prof. Syed Mohamed Aljunid; Rima Semiarty
Asia Pacific Fraud Journal Vol 5, No 1: Volume 5, No. 1st Edition (January-June 2020)
Publisher : Association of Certified Fraud Examiners Indonesia Chapter

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (348.927 KB) | DOI: 10.21532/apfjournal.v5i1.133

Abstract

Indonesia is now encountering moral hazard problems in the implementation of social health insurance. BPJS, as the administrator of Indonesia’s National Health Insurance, reported that there was an increase in deficit in the 4 years of the implementation of National Health Insurance from US$ 228 million in 2014 to US$ 470 million in 2016. Despite efforts conducted to overcome the problem, no evidence-based predictor that might be significantly associated with moral hazard in a rural province hospital in Indonesia. The purpose of this research is to identify the incidence of moral hazard in the implementation of National Health Insurance in Indonesia. Data consisting of 180 medical records obtained from three public hospitals in rural province of Indonesia were selected as samples in this study. These medical records were reviewed by Independent Senior Coder (ISC) who had more than 5 years experiences as a coder. The indicators of moral hazard in this study were upcoding, readmission, and possible unnecessary admission. Logistic regression was used to explore determinant of moral hazard from patient, coder, and physician side. The results show that rate of moral hazard cases for upcoding is 10%, readmission is 2.8%, and possible unnecessary admission is 18.9%. It can be seen from multivariate analysis that discharge status, severity level and LOS have a significant relationship with moral hazard. Illness severity level, Discharge against Medical Advice, and higher Length of Stay are risk factors for moral hazard incidence.
INCIDENCE AND ROOT CAUSE OF UPCODING IN THE IMPLEMENTATION OF SOCIAL HEALTH INSURANCE IN RURAL PROVINCE HOSPITAL IN INDONESIA Syafrawati Syafrawati; Rizanda Machmud; Prof. Syed Mohammed Aljunid; Rima Semiarty
Asia Pacific Fraud Journal Vol 5, No 1: Volume 5, No. 1st Edition (January-June 2020)
Publisher : Association of Certified Fraud Examiners Indonesia Chapter

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (259.545 KB) | DOI: 10.21532/apfjournal.v5i1.135

Abstract

Upcoding is one of important indicators of moral hazard and fraud in Social Health Insurance scheme. However, there seems to be little evidence about incidence of upcoding and how upcoding occurs in hospital, especially in rural province hospital. The objective of this study is to determine incidence and root cause of upcoding in the implementation of Social Health Insurance in Rural Province Hospital in Indonesia. The data used in this study were both qualitative and quantitative data (mixed method). Three hundred and sixty (360) inpatient medical records from six rural province hospitals were examined in this study. Diagnosis and procedure codes recorded in these medical records were re-coded by an independent senior coder (ISC). Codes from hospitals’ coders and codes from ISC were then re-grouped using INA-CBG casemix grouper to determine the casemix groups and the hospital tariffs. If the hospital tariff obtained by hospital coder is higher than that obtained by ISC, it is considered as upcoding. This qualitative study was conducted using Focus Group Discussion (FGD) and in-depth interviews in hospitals located in a rural province of Indonesia. In depth interview was held for two hospital directors and two officers from the Social Security Administrator (Indonesia: BadanPenyelenggaraJaminanSosial/BPJS), an agent that manages the Statutory Health Insurance (SHI). Six clinicians and six coders attended the FGD. We asked open-ended questions about their perceptions on upcoding in hospitals. The interviews were recorded and transcribed verbatim. The transcripts were then thematically analyzed. Upcoding cases were found in 11.9% (43/360) medical records. Upcoding cases were dominated by Deliveries Group 2.8% (10/360) and Female reproductive system Groups 1.7% (6/360). The potential loss of income due to upcoding was IDR 154.626.000 or 9% of hospital revenue. Appointment of non-medical doctors as internal verifiers, lack of clear coding guidelines, lack of training for doctors and coders, and poor coordination between hospital and BPJS to resolve coding disagreement were root causes of upcoding in hospital. Policies to prevent and manage upcoding should be urgently developed and implemented in the Statutory Health Insurance (SHI) program in Indonesia especially to prepare upcoding guidelines, enhance medical coding trainingregularly, increase number of coders and verification staff from medical background, and strengthen coordination for coding problem solving in hospital.
Co-Authors - Afrizal A. Heri Iswanto Abdiana Abdiana Abdiana Adang Bachtiar Afdal Afdal, Afdal Al Hafiz Aladin, Nurul Maulina Alifah, Wasilah Amalia, Vella Amizuar, Yulia Fauziah Anak Agung Gede Sugianthara Angel Laura Anggelina Effendi Anggraini, Dessy Anggrainy, Fenty ANNISA WAHYUNI Aqsha Mutia Qalbi Aqsha Mutia Qalbi Arfiani Rusjdi, Dina Aria Fransiska Ariani, Novita Ashal, Taufik Asterina, Asterina Astiena, Adila Kasni Athiyyah, Salsa Naudzul Ayu Ratna Sari Basyir, Vaulinne Basyir, Vaulline Br Ginting Munthe, Novita Daan Khambri Delmi Sulastri Denas Symond Dian Insana Fitri Dian Pertiwi Diva Indah Pratiwi Em Yunir, Em Erlina Burhan Erly Erly Eva Chundrayetti Fachry Abda El Rahman Fadilla Azmi Fadrian, Fadrian Fahmy, Rahmi Farhan, Ulfa Fadhila Fathiyyatul Khaira Febrian Febrian Febriyanti febriyanti febriyanti Febriyanti Nursa Finny Fitry Yani Firdawati Firdawati, Firdawati Fitri, Shafni Fortuna, Fory Gayatri Gayatri Hamzah, Prima Kurniati Hardisman Harmen, Elsa Luvia Hartati Hartati Helery, Muhammad Arsyan Hidayati Hidayati Hidzra Wafi Habib Hindrya Firsta Ananda Husna Yetti Husna Yetti Ida Rahmah Burhan Ifmaily, Ifmaily Ilmiawati Ilmiawati, Ilmiawati Indrapriyatna, Ahmad Syafruddin Irma Oktavina Zulmi Isniati Jaka Kurniawan Jasman, Putri Elica Jendrius Jendrius Karmia, Hudila Rifa Karynina Danti Putri Kemalayanti, Nursep Kiran Nandini Kurnia, Nurul Syifa Laila Isrona Laila Nur Azizah Laiza Faaghna Lestarii, Rahmi Liesmayani, Elvi Era Linosefa Linosefa Mahyuni, Eni Marpaung, Yahya Masnadi, Nice Rachmawati Masrul Masrul Masrul Maya Amanda Menkher Manjas Mona, Deli Monika, Cici Mudjiran Mudjiran Muhammad Helmi, Iqbal Muhammad Hidayat Muhammad Idrus Muhammad Marzain Munthe, Novita Br Ginting Murni, Melia Rahmadewi Muthia Larasati Muthia, Gabila Heira Najirman Najirman, Najirman Nandini, Kiran Narulita, Jaesica Salsabila Dwi Nelmi Silvia Nelwati, Nelwati Nilda Tri Putri Novfattra Novfattra Novia Putri Nugroho, Faisal Nur Afrainin Syah Nurdin, Aguswan Nusyirwan Effendi Nuzulia Irawati Oktavenra, Ari Pharmaheru, Rahmat Putra Prima Astuti Handayani Priscilla, Hilary Prof. Syed Mohamed Aljunid Prof. Syed Mohammed Aljunid Putra, Abdi Setia Putra, Ikhsan Yusda Prima R Nona Millani Raden Mohamad Herdian Bhakti rafika aini Rafika Oktova Rahmad Gurusinga Rahmadana, Muhammad Haritsyah Rahmaddian, Tosi Rahmaddiansyah, Refa Rahmadhani Rahmadhani Rahmi Yanti Ahdinur Ramayanti Ramayanti Ratni Prima Lita Rauza Sukma Rita Rika Ampuh Hadiguna Rinang Mariko, Rinang Rini Gusya Liza, Rini Gusya Rizanda Machmud Rizanda Machmud Rizki Nur Amalia Rose Dinda Martini Rosfita Rasyid Roslaili Rasyid Rumaisha, Rumaisha Salsabilla Dhiyaa Syifa Septia Endike Shafni Fitri Shinta Dewi, Viola Siregar, Fatia Putri Barokah Siregar, Umi Fadilah Sry Rachmawaty Suci Chairiya Akmal Syafitri Ayu Asyifa Syafrawati Syamel Muhammad Syukri Lukman Tabranny, Hasbullah Taufik Akbar Teguh Imana Nugraha Thomas Darwin Try Wulan Sari Tuti Gusra Ulya Uti Fasrini Vaulinne Basyir Vaulline Basyir Verinita, Verinita Vita Febrina Vitresia, Havriza Wahyuni, Annisa Wanra, Fadhlan Agusma WD, Marryo Borry Wildan Chaniago Wildan Chaniago Winerli Septevani Wirsma Arif Harahap Wulan Dewi Rizky Yanti, Mendhel Yaslinda Yaunin Yonnedi, Effa Yulia, Dwi Yulistini, Yulistini Yulitasari Yulitasari, Yulitasari Yulyfa Kurnia Yulyfa Kurnia Yuniar Lestari Yuniar Lestari Yurniwati Yurniwati Yurniwati Yurniwati Yustini Alioes Zia, Hanim Khalida Zulen, Ilham Andhika Zurayya Fadila