ABSTRACTFraud claim is one cause ofinefticieny in health expenditure. In USA is reported 10%
of health expenditure contain suspected fraudulent cost. Data for Indonesia is rare
because study for health cost Baud in Indonesia is very limited. To get figure and risk
on fiaud in health cost or expenditure in Indonesia, a study has been run with sample
of hospital surgery claim at PT. J amsostek (persero) Bekasi branch office. Criteris for
fraud suspected is inappropriate infomation that given' by hospital and seen at claim
document or patient information. There are 177 cases that got surgery at 3 hospital in
Bekasi on October 2006- March 2007. All of cases are non maternity surgery. Result
of this study are; risk for liaud claim in PT Jamsostek (persero) Bekasi Branch office
is 73,4% of total claim. Factors that related to ti-aud are type of surgeon specialist,
classification of surgery in term oftariffclassitication, urgency of surgery, and quality
of verification person in Jamsostek. This study give infomation that fraud is
potentially could make expenditure for health always increase constantly, because one
of the cause is fraud. Fraud is related with moral and ethic of people, and doctors have
obligation to avoid cheat patient or other party that responsible for claim payment.
Doctors, hospital management and insurance company should work together to reduce
risk of fraud and colaborate to make cally warning system to minimize impact of
iiaud claim to health expenditure and quality of service. Awareness of people should
be built to make every party in health service could avoid tiaud claim.
ABSTRAKKecurangan yang menurut istilah asuransi disebut fraud telah tcrbukti berperan
menimbulkan incfisicnsi pelayanan kesehatan di USA sebesar 10% dari total belanja
kesehatan. Di Indonesia sulit mendapatkan angka pastinya karena terbatasnya
penelitian tentang Baud. Untuk mendapatkan gambaran risiko fraud, dilakukan
penelitian pada klaim pembedahan PT .Jamsostek (Persero) kantor cabang Bekasi
periode Oktober 2006-Maret 2007. Kriteria fraud ditctapkan berdasarkan kesesuaian
informasi di dokumen tagihan dan dokumen pendukung ain sena keterangan pasien.
Sampel yang digunakan adalah total sampel dan terdapat 177 kasus dengan berbagai
jenis pembeclahan. Diteliti berbagai faktor yang mempengaruhi terjadinya fraud.
Diperoleh hasil risiko iiaud klaim pcmbedahan di P'I`.Iamsostek (Persero) kacab
Bekasi sangat tinggi, terbanyak ketidaksesuai tagihan biaya dan tarif tindakan,
sclanjumya ketidaksesuaian diagnosis. Faktdr-faktor yang mempengaruhi fi-and
diantaranya dokter bedah, rumah sakit, jenis spesialisasi, sifat dan klasiiikasi
pembedahan Serta kualitas veriiikator klaim PT. Jamsostek (pcrsero). Diperlukan
kcsadaran bersama untuk mengataslnya yaitu oleh organisasi profesi dokter untuk
membina mom dan etika dokter, rumah sakit dengan pembenahan sistem dan
rnanajemen serta asuransi dengan peninglmtan kompetensi verifikator klaim
T34540-Yulherina.pdf :: Unduh