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All Journal International Journal of Public Health Science (IJPHS) Majalah Kedokteran Bandung Jurnal Kebijakan Kesehatan Indonesia Jurnal Keperawatan Jiwa (JKJ): Persatuan Perawat Nasional Indonesia Jurnal Kesehatan Jurnal Kesehatan Masyarakat Andalas (Andalas Journal of Public Health) Jurnal Kesehatan Andalas Jurnal Administrasi Kesehatan Indonesia STOMATOGNATIC- Jurnal Kedokteran Gigi The Indonesian Biomedical Journal Sari Pediatri Jurnal Kesehatan Paediatrica Indonesiana Jurnal Penelitian Kesehatan Suara Forikes Jurnal Ilmiah Universitas Batanghari Jambi Jurnal Kesehatan Komunitas Jurnal Kesehatan Medika Saintika JCES (Journal of Character Education Society) Indonesian Journal of Cardiology Jurnal Endurance: Kajian Ilmiah Problema Kesehatan B-Dent, Jurnal Kedokteran Gigi Universitas Baiturrahmah JURNAL KESEHATAN PERINTIS NERS Jurnal Keperawatan JIK- JURNAL ILMU KESEHATAN Jurnal Ilmu Keperawatan Jiwa Oto Rhino Laryngologica Indonesiana Majalah Kedokteran Andalas Jurnal Ilmu dan Teknologi Kesehatan Jurnal Riset Hesti Medan Akper Kesdam I/BB Medan Asia Pacific Fraud Journal Padjadjaran Journal of Dental Researchers and Students Jurnal Bidan Cerdas Health and Medical Journal Human Care Journal Contagion: Scientific Periodical Journal of Public Health and Coastal Health Jurnal 'Aisyiyah Medika Andalas obstetrics and gynecology journal Jurnal Ilmiah Permas: Jurnal Ilmiah STIKES Kendal Jurnal Ners Science Midwifery Indonesian Journal of Global Health research Indian Journal of Forensic Medicine & Toxicology Mitra Raflesia (Journal of Health Science) Warta Pengabdian Andalas: Jurnal Ilmiah Pengembangan Dan Penerapan Ipteks JOURNAL LA MEDIHEALTICO Jurnal Ilmu Kesehatan Indonesia (JIKSI) Andalas Dental Journal JKKI : Jurnal Kedokteran dan Kesehatan Indonesia Jurnal Endurance: Kajian Ilmiah Problema Kesehatan Riset Informasi Kesehatan Elevate : The International Journal of Nursing Education, Practice and Research Jurnal Sains, Teknologi dan Kesehatan (Medical Scientific Journal) MESINA Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal)
Rizanda Machmud
Andalas University
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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 - Afrizal A. Aziz Djamal Abdi Setya Putra Abdiana Abdiana Abdiana, Abdiana Adang Bachtiar Addientya Maykeza Adelin, Prima Adrial Adrial, Adrial Afrizal Afrizal Afrizal Afrizal Amelin, Fitrisia Amrin Alkamar Andani Eka Putra Anna Faluzi ANNISA WAHYUNI Apriyeni, Emira Ari Sukma Nela Ariadi, Ariadi Ariescha, Putri Ayu Yessy arif, yulastri Arina Widya Murni Artha Budi Susila Duarsa Audia Tria Putri Ayu Nurdiyan Aziz Djamal Azrimaidaliza Basok, Buhari Bestari Jaka Budiman Bobby Indra Utama Br Ginting Munthe, Novita Candra Deni Mairosa Cantika Dinia Zulda Dally Rahman Dasman, Hardisman DEDI FATRIDA Defriman Djafri Defrin, Defrin Delfilaura, Asyifa Delmi Sulastri Denas Symond Desmiwarti Desmiwarti Desmiwarti Desmiwarti Desy Nofita Sari Devi Gusmaiyanto Dewi Susanti Dhyna Lidya Lestari Dia Rofinda, Zelly Dia Dian Pertiwi Dolly Irfandy Dorisnita Dorisnita Dorisnita Dorisnita dorisnita, dorisnita Dwiana Ocviyanti Edi Efian Edison Edison Effy Huriyati Efrida Efrida Eko Setiawan Ekowati Rahajeng Elly Usman Elyasina Elyasina Emeraldy Chatra Engga Lift Irwanto Eny Yantri Erlina Burhan Esi Afriyanti Evi Hasnita Ezalina, Ezalina Fachry Abda El Rahman Fairuza Muharammy Fakhri, Muhamad Fathiyyatul Khaira Fathiyyatul Khaira, Fathiyyatul Fauziah Elytha Febrina, Raissa Fenty Anggraini Ferdinal Ferry Ferry, Ferdinal Finny Fitri Yani Finny Fitry Yani Firdawati, Firdawati Fitra Dini Fitra Gusfriyanto Fitrayeni Fitrayeni Hamzah, Prima Kurniati Hardisman Harinal Afri Resta Harmawati Harum Nurdinah Haryadi Mangkuto Hasmiwati Hendriani, Intania Dwiputri Hendriati, Hendriati Herman, Deddy Husna Yetti Huvaid, Sevilla Ukhtil Indah Edranovi Putri Indah Syafira Praja Irvan Medison Irvan Medison Irvan Medison Isnati Isnati Isniati Jafril Jafril Jendrius Jendrius Kamal Kasra Kuswardani Susari Putri Lendrawati Lendrawati Leona, Denada Florencia Lili Fajria Lindesi Yanti Linosefa Linosefa M. Abduh Firdaus Mahata, Liganda Endo Mahathir, Mahathir Mahyuni, Eni Maryeti Maryeti Masrul Masrul Mayetti Mayetti Melinda Noer Mery Febriyeni Mike Ayu Wulandari mimi rosiska Mira Susanti Mona, Deli Monalisa Monalisa Mudjiran Muhamad Ivan Munthe, Novita Br Ginting Murniwati Murniwati Murniwati Murniwati Nasman Puar Neherta, Meri Nelwati, Nelwati Nency Agustia Nila Kasuma Nilakesuma, Nur Fadjri Nita Afriani Nopriadi . Novi Yudia Nur Afrainin Syah Nur Indrawati Lipoeto Nur Indrawaty Lipoeto Nurmaines Adhyka, Nurmaines Nursyirwan Effendi, Nursyirwan Nursyrwan Effendi Nurulia Muthi Karima Nusyirwan Effendi Nuzulia Irawati P.A Kodrat Pramudho Prof. Syed Mohamed Aljunid Prof. Syed Mohammed Aljunid Putri Nelly Syofiah Putri Nilam Sari Putri Sri Lasmini Putri Sri Lasmini, Putri Sri R Nona Millani Rahayuningsih, Atih Rahmad Gurusinga Rahmat Syawqi Rasyid, Hauda El Ratna Lestari Habibah Rena Regina Erwin Reni Prima Gusty Renty Ahmalia Rika Sarfika Rima Berlian Putri Rima Semiarty Rima Suryani Rina Jumita Rismawati Yaswir Riza Yefri Rizki Rahmadian Rohim, Muhamad Fatchur Rosdiyanto, Rosdiyanto Rosfita Rasyid Roslaili Rasyid Rosmeri Rosha Rosmery Rosmery Rozi Sastra Purna Rulifa Syahroel Russilawati, Russilawati Sari, Nur Mala Sari, Yulia Margaretta Soetrisno Soetrisno Soetrisno Soetrisno Suci Rahmasari Sukri Rahman Surya Nelis Susi Erianti Suspenti Dewi Syafrawati Syahredi Adnani Utami, Sherly Putri Vera Sesrianty Vitro Darma Yusra Vivi Syofia Sapardi Wahyuni, Annisa Widayat Alviandi Widiya Wati Yan Edward Yandrizal Yandrizal Yanni, Mefri Yantri Maputra Yashinta Octavian Setyanda Yaslinda Yaunin Yefri Zulfiqar Yenita . Yolazenia Yolazenia Yonrizal Nurdin Yudhia Fratidhina Yulia Efni Yulia Margaretta Sari Yuliarni Syafrita Yunarti Yunarti Yundari, Yundari Yuniar Lestari Yuriko Andre Yurniwati Yurniwati Yusrawati Yusrawati Zia, Hanim Khalida