ABSTRACT Fraud claim is one cause ofinefticieny in health expenditure. In USA is reported 10%of health expenditure contain suspected fraudulent cost. Data for Indonesia is rarebecause study for health cost Baud in Indonesia is very limited. To get figure and riskon fiaud in health cost or expenditure in Indonesia, a study has been run with sampleof hospital surgery claim at PT. J amsostek (persero) Bekasi branch office. Criteris forfraud suspected is inappropriate infomation that given' by hospital and seen at claimdocument or patient information. There are 177 cases that got surgery at 3 hospital inBekasi on October 2006- March 2007. All of cases are non maternity surgery. Resultof this study are; risk for liaud claim in PT Jamsostek (persero) Bekasi Branch officeis 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 qualityof verification person in Jamsostek. This study give infomation that fraud ispotentially could make expenditure for health always increase constantly, because oneof the cause is fraud. Fraud is related with moral and ethic of people, and doctors haveobligation to avoid cheat patient or other party that responsible for claim payment.Doctors, hospital management and insurance company should work together to reducerisk of fraud and colaborate to make cally warning system to minimize impact ofiiaud claim to health expenditure and quality of service. Awareness of people shouldbe built to make every party in health service could avoid tiaud claim. ABSTRAK Kecurangan yang menurut istilah asuransi disebut fraud telah tcrbukti berperanmenimbulkan incfisicnsi pelayanan kesehatan di USA sebesar 10% dari total belanjakesehatan. Di Indonesia sulit mendapatkan angka pastinya karena terbatasnyapenelitian tentang Baud. Untuk mendapatkan gambaran risiko fraud, dilakukanpenelitian pada klaim pembedahan PT .Jamsostek (Persero) kantor cabang Bekasiperiode Oktober 2006-Maret 2007. Kriteria fraud ditctapkan berdasarkan kesesuaianinformasi di dokumen tagihan dan dokumen pendukung ain sena keterangan pasien.Sampel yang digunakan adalah total sampel dan terdapat 177 kasus dengan berbagaijenis pembeclahan. Diteliti berbagai faktor yang mempengaruhi terjadinya fraud.Diperoleh hasil risiko iiaud klaim pcmbedahan di P'I`.Iamsostek (Persero) kacabBekasi sangat tinggi, terbanyak ketidaksesuai tagihan biaya dan tarif tindakan,sclanjumya ketidaksesuaian diagnosis. Faktdr-faktor yang mempengaruhi fi-anddiantaranya dokter bedah, rumah sakit, jenis spesialisasi, sifat dan klasiiikasipembedahan Serta kualitas veriiikator klaim PT. Jamsostek (pcrsero). Diperlukankcsadaran bersama untuk mengataslnya yaitu oleh organisasi profesi dokter untukmembina mom dan etika dokter, rumah sakit dengan pembenahan sistem danrnanajemen serta asuransi dengan peninglmtan kompetensi verifikator klaim
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