5 Common Types of Fraud in Health Services
There is no health service in the world that is truly free from fraud. Basically, fraud occurs because there are opportunities, rationalization, and motivation. In Indonesia, the Social Security Administering Body (Badan Penyelenggara Jaminan Sosial/BPJS) as the organizer of the National Health Insurance (Jaminan Kesehatan Nasional/JKN) is not spared from fraudulent practices.
It is this fraud that is alleged to be one of the factors BPJS continues to experience a deficit that is estimated to reach Rp 16.5 trillion this year. In addition to deficits, fraud also creates moral hazard for the community as recipients of services.
Who is the culprit? Potential fraud can come from many parties; individual BPJS, the provider of goods and services, healthcare providers, or the participant.
In general, there are five types of fraudulent acts that commonly occurred in health services:
- Upcoding – The healthcare provider submits inaccurate billing code in order to get inflated reimbursement from the insurance. For example, a patient with type 2 diabetes is coded with type 2 diabetes but the code is added with other complication.
- Phantom billing – The healthcare provider submits a bill for a service that actually does not exist.
- Inflated bills – Any actions that make the bill becomes inflated.
- Canceled service – The healthcare provider cancels a service, but the service is still billed.
- Unnecessary care – The health care provider performs a service which is not needed by patients. Example: the patient has to have an appendix operated when he doesn’t need it.
Then, how to prevent it?
Different types of fraud, different methods of prevention. BPJS has strived to prevent fraud by implementing a layered system from registration to claim fees. Basically, it is done by verifying each data or information at each stage of services. For example, the officer will cross-check the identity of the patient at the time of registration to prevent fraudulent use of other people’s cards.
The most important thing in preventing fraud in any industry is the awareness of stakeholders to participate in the effort. No matter how good the method used, if the stakeholders do not own the awareness, the potential for fraud is greater.