부산대학교 도서관

The health insurance program (is called JKN) implementation in the national social security system found various problems. One of them is the potential for fraud, which could cause harm to the national social security fund. Fraud is an act of not following the regulations of the government that is done intentionally by participants and health workers. The government regulations have been issued relating to preventing fraud in the JKN system. Upcoding is one of the incidents of fraud in JKN. The establishment of a unit of officers in preventing fraud has been written in the Joint Decree on the Joint Team for Fraud Handling of JKN. This study aims to see how hospital management to prevent fraud. The method used in this research is a qualitative method using open-ended question instruments. The results of this study found that the fraud prevention team of JKN was formed at the hospital. Unfortunately, it has not been able to work optimally due to the absence of clear rules about carrying out the task. The incidence of fraud in hospitals is due to inaccurate coding, which is one of the causes, including the difference between diagnoses based on ICD (International Statistical Classification of Diseases and Related Health Problems) 10 and codes for the benefit of claims that refer to BPJS (Health Social Security Administration Bodies/ is called BPJS) regulations. It is also caused by a lack of supporting data in determining the diagnosis. So, the need for policies from the hospital management to plan measures to prevent fraud by involving all essential elements, optimizing the role of the team, and coaching employees. [ABSTRACT FROM AUTHOR]