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All Journal Jurnal Kebijakan Kesehatan Indonesia Jurnal Kesehatan Masyarakat Andalas (Andalas Journal of Public Health) Jurnal Kesehatan Andalas Jurnal Kesehatan AcTion: Aceh Nutrition Journal Jurnal Kesehatan Komunitas Jurnal Ilmu Kesehatan JURNAL KESEHATAN PERINTIS Jurnal Hilirisasi IPTEKS (JHI) Buletin Ilmiah Nagari Membangun JIK- JURNAL ILMU KESEHATAN Asia Pacific Fraud Journal Warta Pengabdian Andalas: Jurnal Ilmiah Pengembangan Dan Penerapan Ipteks JEMIL
Syafrawati
Fakultas Kesehatan Masyarakat Universitas Andalas
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Journal : Asia Pacific Fraud Journal

 1 
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 Abd. Rasyid Syamsuri Ade Suzana Eka Putri Ahmad Hidayat Ahmad Hidayat Annisa Afritika Ayulia Fardila Sari Ayulia Fardila Sari ZA Defriman Djafri Dien Gusta Aggraini Nursal Dien Gusta Anggraini Nursal Fachrizal, Indra Fitia Oktari Fitri Yani Arbie Habibah, Annisa Nurul Hamidatul Yuni Hamzah, Prima Kurniati Heru Satria Nanda Putra Ice Yolanda Puri Indra Domili Indra Fachrizal Khairunnisa, Muthia Laa Tania Fizikriy Laila Isrona Larasati, Novia M Anas Anasiru M. Ikhsan Novind M. Ikhsan Novind Masrizal Masrizal Masrizal Masrizal Mega Utami Basra Mutia Mutia, Mutia Nadya Vebrielna Nadya Vebrielna Nia Oktavina Nia Oktavina Nugroho Tundun Pesona Dessritina Prima Kurniati Hamzah Prof. Syed Mohamed Aljunid Prof. Syed Mohammed Aljunid Rahma Labatjo Ramadani, Mery Ratno Widoyo, Ratno Rayunda Chikita Rayunda Chikita Oktari Rayunda Chikita Oktari Rima Semiarty Rizanda Machmud Shelvy Haria Roza Silvia Argameli Sindi Maulani Sindi Maulani Sri Siswati Syahirah, Nada Tri Hazka Vitratul Ilahi Vivi Triana Vivi Triana