494 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No.

The Implementation of Fraud Prevention on the National

Health Insurance at Salewangan Maros Hospital, Indonesia: A
Qualitative Study

Fitri Indayani1,2, Reza Aril Ahri2,3, A. Rizki Amelia2,3, Fatmah Afriyanti Gobel2,3, Fairus Prihatin Idris2,3,
Andi Surahman Batara2,3
1
Magister Program in Public Health, Universitas Muslim Indonesia, Makassar, South Sulawesi, Indonesia, 2
National Health Insurance, South Sulawesi Branch, Makassar, Indonesia, 3Departement of Public Health, Faculty
of Public Health, Universitas Muslim Indonesia, Makassar, South Sulawesi, Indonesia

Abstract
Background: Various fraud control methods are designed to overcome potential fraud that occurs by
every element that involved in the National Social Health Insurance System in Indonesia. This study
aims to analyze how the implementation of fraud prevention efforts that have been carried out by the
National Health Insurance (JKN) Fraud Prevention Team which was formed at the SalewanganMaros
Regional Hospital. Method: This study used a descriptive qualitative approach with data collection
techniques through in-depth interviews and observation. The informants were the Head of the Service
Division, the Chair of the Hospital Medical Committee, the Head of the Nursing Sub-Division, the Head
of the Finance Sub-Division, and the Casemix team.Results:Efforts to increase the fraud prevention is
still weak, efforts to detect and resolve fraud are already underway, but efforts to detect fraud have not
been continuous, detection through observation at service locations is not routinely carried out, while
detection efforts through data analysis still rely on service data feedback obtained from BPJS, as well
as monitoring and evaluation by the Fraud Prevention Team at SalewanganMaros Regional Hospital
has been implemented but is still very poor.Conclusion: Fraud prevention efforts must be carried out
comprehensively and involve all individuals. There must be an automated integrated system at each
service point so that fraud prevention can be optimized.

Keywords: Fraud Prevention, Indonesia, National Health Insurance

Background A membership comprising 222.8million people in

April 2021, the program is one of the biggest health
Indonesia’s health coverage program, the National
insurance in the world [1]. Fraud can be seen in all
Health Insurance (JKN) program, is administered
insurance types including health insurance. Fraud in
by Health Care and Social Security Agency (BPJS).
health insurance is done by intentional deception or
misrepresentation for gaining some shabby benefit in
Corresponding Author: the form of health expenditures [2, 3]. In the United
Andi Surahman Batara States, which is a developed country, reported by
Email: surahmanbatara@gmail.com the General Accounting Office (GAO) in 1990,
Address:Jln. UripSumoharjo No.05, Panakukang claims for indications of fraud were recorded at
District, Makassar City, South Sulawesi, Indonesia, around US $ 100 billion or 10% of the total health
90231, Phone: +6281354760930 costs per year [4].
 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1 495

Further, based on a survey conducted by the by every element that involved in the National
Association of Certified Fraud Examiners (ACFE) Health Insurance System in Indonesia. Through
in 2010, fraud on Health Care was in fourth place at presidential regulation number 82 of 2018 and its
7.3%, and Indonesia was in third place with the highest derivate regulations, it is mandatory for Stakeholders,
number of cases out of 30 countries surveyed[5]. Health Department, BPJS,and Health Facilities which
Fraud on Health Service Providers (PPK), especially cooperating with BPJS to build a fraud prevention
Hospitals can be caused by Hospital dissatisfaction system and done systematically, structured, and
with INACBG rates (Indonesia Case Base Groups), comprehensive by engaging all human resources.
an application used by hospitals to file claims to the
Taking into account the findings from the audit
government) and unpreparedness of Information
of the State Development Audit Agency(BPKP) at
Technology systems in Hospitals. In addition, the
the SalewanganMaros Regional Hospital in 2018
motivation to seek “economic gain” could lead PPK
with the result that there were 51 cases, including 6
to commit fraud[6].The causative factor itself consists
cases of readmission and 45 cases of multiple claims
of high unmet needs and low salaries received which
(fragmentation, unbundling, cloning), even more
can result in employees taking actions that have the
there are problems with delays in claim submissions
potential to be fraudulent[7, 8].
which is indicate that there a problems of governance
In addition, if aninternal control of the company’s system at SalewanganMaros Hospital in the year of
is work weakly, the possibility of errors and fraud is 2020.
increasing[9, 10]. As an example fraud can result in
As mention in the Presidential Regulation number
losses for Manggala Regional Hospital in Indonesia
82 of 2018 article 93 paragraph 3 states that BPJS,
because claims for services that have been performed
Health Department and Hospital must build fraud
cannot be paid [6]. A research was conducted by
prevention system through, developing policies
in-depth interviews in Indonesia, the interviewed
and guidelines for fraud prevention, developing an
informants had knowledge regarding the control of
enhancement fraud prevention culture, developing
potential fraud at dr. AchmadMoechtar Bukit Tinggi,
the high quality and cost oriented health services
the results of the interview were the factors in the
and forming a fraud prevention team. Then as a form
potential for fraud at dr. AchmadMoechtar as follows;
of obedience on that regulation, fraud prevention
differences in payment systems, the INA CBGs
teams that was formed at the SalewanganMaros
payment system is a prospective payment system,
Regional Hospital based on the Director’s Decree of
while the payment system for dr. AchmadMoechtar
the Fraud Prevention Team at the SalewanganMaros
Hospital still uses the Governor Regulation
Regional Hospital in 2020, Number 197/24 / RSUD
Number 58 of 2015 on Health Service Rates for dr.
/ 2020, the duties of the Fraud Prevention Team is
AchmadMoechtarBukittinggi by using a fee-for-
Conduct early detection of JKN fraud based on data
service payment system. Factors that can hinder the
on health service claims conducted by the hospital.
potential for fraud at dr. AchmadMoechtarBukittinggi,
Disseminating new policies, regulations, and culture
by implementing Standard Operational (SOP) and
oriented towards quality control and cost control.
Clinical Pathway can prevent potential fraud, Based
Encourage the implementation of good organizational
on in-depth interviews from informants, RSUD Dr.
governance and clinical governance Increase the
Low birth weight (LBW) and non-haemorrhagic
ability of Coder and Doctors and other officers related
stroke [9].
to claims Make efforts to prevent, detect and prosecute
Furthermore, various fraud control methods are JKN fraud monitoring and evaluation.Based on the
designed to overcome potential fraud that occurs background above this study aims to analyze how the
496 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1

implementation of fraud prevention efforts that have data, and third is making conclusions. Data analysis
been carried out by the National Health Insurance begins with preparing and organizing data (text data
(JKN) Fraud Prevention Team which was formed at in the form of transcripts or documents) for analysis,
the SalewanganMaros Regional Hospital. then the next stage is done by reducing the data to
themes through the coding process, and summarizing
Methods
the code and the final stage presenting the data in
This is a descriptive qualitative study thatusedtypes the form of analysis.To ensure the validity of the
of data such as opinions, facts, knowledge, with data data in this study, researchers used triangulation by
sources from ordinary informants and key informants. validating information by looking at the consistency
Data collection techniques were used in-depth of information obtained by researchers through in-
interviews with a structured interviews guideline. depth interviews. The data analysis using Nvivo 12 (a
The data analysis technique was carried out in three qualitative software).
stages; first, reducing the data, second describing the

Results
Table 1. The Empirical findings of the improvement of the fraud prevention culture

Respondent Fraud Prevention Culture

Claim verification control is not layered between casemix team and fraud prevention team
FA
Dispute claim remain

Delay in payment of services fees

IA No socialization of fraud prevention in the hospital and no technical meeting to discuss the teams
duties

The audit findings and result received and executed according to the provisions without discussing
YU
the prevention how should it not be repeated

Table 2. The empirical findings of the implementation of organizational governance and clinical governance

Respondent Good Organizational Governance and Good Clinical Governance

Claim submission to the Payer (BPJS) is delayed in process.

IA Consumable medical material less provide about 70% and it is mostly substitute which low quality
below the standards

FA Clinical pathway is not complete

SW Medical record and Information system is still combining manual and digital process
 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1 497

Table 3. The empirical findings of the detection and settlement of fraud (fraud) at the hospital
Respondent Detection and settlement of fraud
Information System did not provide utilization data for analysis
IA
Patients complaint did not fully conveyed

Whistle blowing system did not provide by the management and fraud prevention teams. The Employee
FA
have no access and remain afraid of the action consequences due to the fraud potential reported

Bed occupancy rate is not being analyzed to the amount of population and not customized with the length
SR
of stay of each patient.

Table 4. The empirical findings monitoring and evaluation carried out by the Hospital fraud prevention
team

Respondent Monitoring and evaluation

Field observation direct to the services point’s was not routinely implemented
There is no task details, technical instructions or implementation guidelines was made to help the
IA teams. And no plan of action arranged.
Medical committee consisting of the specialist and subspecialist doctors was not attained the meeting to
discuss fraud prevention due to limited facilitation.

No person in charge to do the monitoring routinely

FA
Some member of the teams have current positions and hard to manage time and people

The fraud prevention team at SalewanganMaros the culture of fraud prevention, such as a lack of
Regional Hospital, which consists of management desire to change, indifference, busyness, and lack of
(structural) elements, the Hospital Internal communication. Fraud is considered taboo to discuss,
Supervisory Unit (SPI), the Medical Committee and because it damages self-image and organization. So
Casemix have tried to prevent fraud, but some things it tends to be discussed in private and confidential[2].
are still not optimally implemented. Referring to the
Secondly, the implementation of good
research objectives and interview result, we found 4
organizational governance and clinical governance in
major findings:
the hospital is quite good, but needs to be improved
The first, efforts to increase the fraud prevention in several aspects. Efforts to apply the principle
that are being carried out are still poor and not working of accountability are shown by the availability of
well. The difficulty of managing schedules with the standard operating procedures, but clinical guidelines
various activities of each team and the conditions for all disease management are incomplete. This is
of the COVID-19 pandemic that occurred in 2020 slightly different in the application of the principles
has made it even more difficult. Bringing together a of openness and accountability related to filing claims
team of structural elements with a team of functional and calculating medical services. Claims submitted
elements. Cultural changes in fraud prevention have late and not in accordance with the provisions of
not been initiated by the management and fraud the submission routine. Meanwhile, some specialist
prevention team. Anti-fraud commitment signatures, doctors have difficulty calculating the action compared
anti-fraud posters and other new things have not been to the medical services received, and also complaints
implemented. There are still several factors inhibiting about the delay in distributing medical services[11, 12].
498 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1

Thirdly, efforts to detect and resolve fraud are Discussion

already underway, but efforts to detect fraud have
According to Priantara (2013: 48), the fraud
not been continuous, detection through observation
triangle consists of three conditions that are
at service locations is not routinely carried out, while
generally present when fraud occurs, namely: 1).
detection efforts through data analysis still rely on
Pressure to commit fraud (pressure). Pressure can
service data feedback obtained from BPJS. It still
be divided into 4 types, namely: financial problem,
needs hard work from the fraud prevention team to
being involved in a crime or not in accordance with
sit down together to formulate structured preventive
the norm, work-related stress and other pressures.
measures, create a whistleblower that is safe, reliable
2). Opportunity or opportunity to commit fraud
and confidential. Fraud settlement is carried out
(opportunity); weak internal control system, poor
after the audit findings, by deducting claims, which
organizational governance and a pretext to justify
will result in reduced operational costs, difficulties
action (rationalization). Rationalization occurs
in financial management and even losses for the
because someone seeks justification for activities that
hospital. Therefore, it can also be seen that the higher
contain fraud. Fraud perpetrators believe or feel that
the number of fraud findings, the lower the team’s
their action is not a fraud but is something that is their
performance in preventing fraud[11].
right, sometimes even the perpetrator feels that he has
Fourth, monitoring and evaluation by the Fraud done a lot for the organization[13, 14].
Prevention Team at SalewanganMaros Regional
Fraud prevention system according to Ministry
Hospital has been implemented but is still very poor.
of Health (Permenkes No. 36 of 2015) namely:
Monitoring is carried out by officials in concurrent
1).advanced level of healthcare facilities(FKRTL)
positions, there are no detailed tasks yet to carry out
compiles internal regulations in the form of good
monitoring in any way. Meanwhile, the evaluation has
organizational governance and clinical governance.
not been carried out continuously. The difficulty in
2) FKRTL is able to develop health services that
evaluating was due to the difficulty of managing time
are oriented towards quality control and cost control
and gathering all teams to conduct regular meetings
through the use of effective and efficient management
and evaluations.
concepts, evidence-based information technology
In addition, the driving actors for the potential for and forming the JKN Fraud Prevention Team at
fraud at the SalewanganMaros Regional Hospital are the FKRTL. 3) FKRTL is able to develop a JKN
the lack of understanding regarding fraud, specialist fraud prevention culture as part of organizational
doctors, verifiers, coders do not fully understand the and clinical governance oriented towards quality
use of the state budget that must be accounted for and control and cost control based on the principles of
patients are consumers who must be provided with TARIK (transparency, accountability, responsibility,
quality, effective and efficient services. Complaints independence and fairness) [6, 15].
about real hospital rates with INA CBGs rates also
Based on Permenkes No. 36 of 2015, the JKN
become a rationalization for fraud. If there is a dispute
Fraud Prevention Team at the FKTP took action
of opinion regarding the determination of whether or
against JKN fraud and resolved the JKN dispute
not JKN fraud exists, the Provincial Health Office or
settlement based on a report or discovery. As stated in
District / City Health Office can forward the complaint
Article 16 Permenkes No. 36 of 2015, they are:
to the JKN Fraud Prevention Team formed by the
Minister. 1). Transparency is the openness of information,
both in the decision-making process and in disclosing
information in accordance with the need for the
 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1 499

prevention of JKN fraud. 2). Accountability is the The driving factors for the potential for fraud at
clarity of the function of the system structure and the SalewanganMaros Regional Hospital are the lack
service accountability so that management is carried of understanding regarding fraud, specialist doctors,
out effectively. 3). Responsibility is conformity or verifiers, coders do not fully understand the use of the
compliance in service management with the principles state budget that must be accounted for and patients
of a healthy organization in the context of preventing are consumers who must be provided with quality,
JKN fraud. 4). Independence is a condition in which effective and efficient services. Complaints about
an organization is managed professionally without real hospital rates with INA CBGs rates also become
conflict of interest and influence or pressure from any a rationalization for fraud. Cultural changes in fraud
party that is not in accordance with the principles of prevention have not been initiated by the management
a healthy organization in the context of preventing and fraud prevention team. Anti-fraud commitment
JKN fraud. 5). Fairness is a fair and equal treatment in signatures, anti-fraud posters and other new things
fulfilling stakeholder rights arising from an agreement have not been implemented. There are still several
in the context of preventing JKN fraud[15]. factors inhibiting the culture of fraud prevention, such
as a lack of desire to change, indifference, busyness,
Furthermore,Permenkes No. 36 of 2015,
and lack of communication. Fraud is considered
guidance and supervision of the prevention of
taboo to discuss, because it damages self-image and
JKN fraud at the Menggala Hospital has involved
organization image. So it tends to be discussed in
hospital supervisory bodies, hospital supervisory
private and confidential.
boards, hospital associations / associations, and
professional organizations. One of the components Recommendations
in the supervision is to oversee compliance with the
The fraud detection need tools and big data
application of hospital ethics, ethics profession, and
analysis to be able to find where the place is over loss
laws and regulations including Permenkes No. 36 of
or fraud happened at SalewanganMaros Hospital.
2015.For complaints of alleged JKN fraud, it must
SalewanganMaros Hospital need to strengthen
include at least: the identity of the complainant, the
the hospital information system, digitalization
name and address of the agency suspected of carrying
of the patient registration and automation and
out JKN fraud, and the reasons for the complaint
implementation of e-medical records..
(Permenkes No. 36 of 2015). With the JKN fraud
complaint, the head of health facilities, the District Lack of routinely monitoring is carried out
/ City Health Office and / or the Provincial Health by officials in concurrent positions, and there are
Office must follow up on the complaint by conducting no guidelines made or detailed tasks to carry out
an investigation. The investigation was carried out by monitoring in any way. Meanwhile, the evaluation has
involving BPJS, the JKN Fraud prevention team at not been carried out continuously. The difficulty in
hospital[15]. evaluating was due to the difficulty of managing time
and gathering all teams to conduct regular meetings
Conclusion
and evaluations.
The fraud prevention teams at SalewanganMaros
Regional Hospital, which consists of management The fraud prevention team needs to be more
(structural) elements, the Hospital Internal intense in holding meetings or compiling a work
Supervisory Unit (SPI), the Medical Committee and plan, formulating matters or findings submitted by the
Casemix have tried to prevent fraud, but some things auditor, then discussing steps to prevent it to happening
are still not optimally implemented. again. The prevention team determines future action
500 Indian Journal of Forensic Medicine & Toxicology, January-March 2022, Vol. 16, No. 1

plans, establishes appropriate control mechanisms Tulang Bawang). FIAT JUSTISIA: Jurnal Ilmu
according to hospital conditions, then also establishes Hukum, 2016. 10(4): p. 715-732.
a path for complaints (whistleblowing system) of 7. Adisasmito, W., Analisis pengaruh dimensi
violations or fraud through media, correspondence or
fraud triangle dalam kebijakan pencegahan fraud
email.
terhadap program jaminan kesehatan nasional
Acknowledgement: Greatest thanks di RSUP nasional cipto mangunkusumo. Jurnal
that all author want to express toSalewanganMaros Ekonomi Kesehatan Indonesia, 2016. 1(2).
Hospital. 8. Morris, L., Combating fraud in health care: an
Funding: Source of findings is National Health essential component of any cost containment
Insurance, South Sulawesi Branch, Makassar, strategy. Health Affairs, 2009. 28(5): p. 1351-
Indonesia. 1356.
9. Natasya, T.N., H. Karamoy, and R. Lambey,
Conflict of Interest: None
Pengaruh Komitmen Organisasi Dan
Ethical Clearance: Ethical Clearance taken Pengendalian Internal Terhadap Resiko
from The Commission of Health Research Ethic, Terjadinya Kecurangan (Fraud) Dalam
Universitas Muslim Indonesia with registration Pelaksanaan Jaminan Kesehatan Di Rumah
number UMI032101034. Sakit Bhayangkara Tk. Iv Polda Sulut. GOING
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