The Effectiveness and Sustainability of Fraud Prevention Policies in Improving the Quality of Hospital Services in Malang

Puguh Priyo Widodo; Firdaus Hafidz A Shidieq; Likke Prawidya Putri

doi:10.26905/ap.v10i1.12538

The Effectiveness and Sustainability of Fraud Prevention Policies in Improving the Quality of Hospital Services in Malang

Puguh Priyo Widodo, Firdaus Hafidz A Shidieq, Likke Prawidya Putri

Abstract

The National Health Insurance Program (JKN) is implemented with many policies. One of the policies of the JKN program is controlling the quality and cost of health services, a policy on controlling fraud in health services. The objective is to evaluate the effectiveness and sustainability of fraud prevention policies in improving the quality of hospital services in Malang. This study uses a realist evaluation (RE) approach, namely the evaluation of the form of context-mechanism-outcome (CMO) configuration. This approach is to understand the mechanism of what happened and the context in which a program can run or not. The research object was a hospital in Malang with research subjects being the director of the hospital, the deputy director/head of service and support, the deputy director/head of finance, the head of the anti-fraud team, the head of the quality and cost control team, and the head of insurance/casemix. The sample selection used purposive sampling and data collection through interviews, Data was collected using triangulation techniques through analysis of Minister of Health regulation number 16 of 2019. Result findings, that the hospital already has a Fraud Prevention Team as a technical requirement to extend cooperation with BPJS Kesehatan. The structure and functions of the Team have not been realized in a stipulation containing job descriptions, responsibilities and authorities. Hospitals also do not yet have policies, guidelines, standard operating procedures and work programs. Conclusion, that the context-mechanism-outcome aspect of the fraud prevention policy in the JKN program in hospitals is not working.

Keywords

fraud prevention policies; hospital; national health insurance program realist evaluation

Full Text:

PDF

References

Agrawal S, Tarzy B, Hunt L, Taitsman J, dan Budetti P. (2013). Expanding Physician Education in Health Care Fraud and Program Integrity. Acad Med. 2013;88:1081–1087.

AHIMA Foundation. n.d. Tone At The Top: How Management Can Prevent Fraud In The Workplace. /. Retrieved (/www.dmcpas.com/2015/pada 10 Oktober 2020).

Better Evaluation. (2020). Realist Evaluation. Retrieved (https://www.betterevaluation.org /en/approach/realist_evaluation).

Deloitte, Fraud policies – Why you need one and what it should look like, diunduh dari https://www2.deloitte.com/nz/en/pages/finance/articles/fraud-policies- why-you-need-one.html#

Doody, Helena, (2020), Developing an Anti-Fraud Culture, diakses di http://www.the-financedirector.com/features/feature81325/index.html

Fursov, I., Zaytsev, A., Khasyanov, R., Spindler, M., & Burnaev, E. (2019). Sequence embeddings help to identify fraudulent cases in healthcare insurance. Journal of Econometrics, 1910.03072, 1–28

Gee, J., Button, M., & Brooks, G. (2011). The Financial Cost of Healthcare Fraud (what data from aroun the world shows) 2011 Report. PKF (UK) LLP And University Of Portsmouth.

Grant TM. 2017. “Leadership Strategies for Combating Medicare Fraud.”

Greenhalgh, T., et. al. (2015). Protocol-the RAMESES II Study: Developing Guidance and Reporting Standrds for Realist Evaluation. BMJ Open. doi: 10.1136/bmjopen-2015-008567.

Greenhalgh, Trisha, Geoff Wong, Justin Jagosh, Joanne Greenhalgh, Ana Manzano, Gill Westhorp, and Ray Pawson. (2015). Protocol-the RAMESES II Study: Developing Guidance and Reporting Standards for Realist Evaluation. BMJ Open 5(8). doi: 10.1136/bmjopen-2015-008567.

Indonesia, Republik. (2011). UU No 24 (2011) - BPJS. Phys. Rev. E (July):37.

Kazi, Mansoor., A. .. (2003). Realist Evaluation in Practice: Health and Social Work. New Delhi.

L, Dean PC; Vasquez-Gonzalez J;Fricker. (2013). Causes and Challenges of Healthcare Fraud in the US. International Journal of Business and Social Science Vol.4 (14):1–4.

Manghani, Kishu, (2011), Quality assurance: Importance of systems and standard operating procedures, Perspesctive in Clinial Research, 2(1), 34 – 37.

National Healthcare Anti-Fraud Association (NHCAA). (2007). The NHCAA Fraud Fighter’s Handbook. A Guide to Healthcare Fraud Investigations&SIU Operations. New York.

Pawson, R., Tilley, N. (1997). Realistic Evaluation. London: SAGE Publication Asia Pasific Pte.Ltd.

Peraturan Presiden No.82 Tahun 2018, Pasal 95. n.d. Jaminan Kesehatan.

Peraturan Menteri Kesehatan No. 16 Tahun. n.d. (2019). Pencegahan Dan Penanganan Kecurangan (Fraud) Serta Pengenaan Sanksi Administrasi Terhadap Kecurangan (Fraud) Dalam Pelaksanaan Program Jaminan Kesehatan.

Price, M&Norris, D. .. (2009). Health Care Fraud: Ph Ysicians as White Collar Criminals? Journal of the American Academy of Psychiatry and the Law Onlin 37(3):286–89.

Ranmuthugala, Geetha, Cunningham, Frances C, Plumb, Jennifer J, Long, Janet; Georgiou, Andrew, Wesbrook, Johanna I, Braithwaite, Jeffrey. (2011). A Realist Evaluation of the Role of Communities of Practice in Changing Healthcare Practice. Implementation Science 1–6.

Rowe, J&Kellam, C. n.d. (2017), Ethics and Moral Development: Core Ingredients of a Compliance Culture. Home Health Care Management&Practice 23(1):55–59.

S.Nostratnejad, A. Rashidian, A. Akbari Sari, and N. Moradi. (2017). “Willingness to Pay for Complementary Health Care Insurance in Iran.” Iran J.Public Health Vo. 46 No.:1247–55.

Sekretaris Negara RI. 2004. “UU RI No.40 Tahun 2004 Tentang Sistem Jaminan Sosial Nasional.” Jdih BPK RI 1–45.

Wong, G., Westhorp, G. Manzano, A., Greenhalgh, J., Jagosh, J., Greenhalgh, T. (2016). RAMESES IIreporting Standards for Realist Evaluations.

Torpey, Dan, dan Sherrod, Mike, (2011), Who Owns Fraud?, Fraud Magazine, diakses di https://www.fraud-magazine.com/article.aspx?id=4294968975

DOI: https://doi.org/10.26905/ap.v10i1.12538

Refbacks

There are currently no refbacks.

Indexing by

Index Copernicus International (ICI)

Tools:

Supported By:

JURNAL AKUNTANSI DAN PERPAJAKAN

Fakultas Ekonomi dan Bisnis
Universitas Merdeka Malang

Mailing Address:

Jalan Terusan Raya Dieng 62-64 Malang
East Java, Indonesia
Phone: 085855234000
Email: akuntansi.pajak@unmer.ac.id

Username
Password
Remember me