Phenomenon of Causal Fraud Health Insurance in Hospitals: Theory of gear fraud

Abstract

Objective: To describe and explore the experiences of hospital employees with the causes of fraud in the health insurance program at the hospitals.

Design And Setting: This research was carried out at government hospitals in the Southeast Sulawesi Province in collaboration with BPJS Health, namely the Bahteramas Regional General Hospital and the Kendari City Regional General Hospital. Triangulation was carried out at BPJS Health, the Center for Health Insurance Financing at the Ministry of Health and the Center for Health Policy and Management at Gadjah Mada University, Yogyakarta. This research was conducted for one year, namely January 2020 to February 2021qualitative method with a phenomenological approach. Data collection methods were carried out through in-depth interviews, focus group discussions, and document studies. The number of participants in this study was 44 people consisting of doctors in charge of services, nurses, midwives, and case-mix team including coders who met the inclusion criteria. Data analysis used the Moustakas method.

Result: The causes of health insurance fraud in hospitals financial motives (the desire to get money or material or economic or welfare benefits, get high service services and low employee salaries), behavioral motives (low integrity, lifestyle and employee habits of committing fraud0, and social motives (kinship, humanitarian factors, avoiding conflict, social position, and the existence of pressure), internal controls (a weak monitoring system, poorly enforced regulations, unclear regulations and limited hospitals providing services, no monitoring and evaluation, and there are no sanctions for fraud perpetrators), revenue targets (hospitals income and increasing the number of claims), leadership (leadership style or weak leadership in the hospitals and the absence of transparency), incentive systems (poor distribution of incentives and the absence of transparency of services from hospitals management), National Health Insurance (NHI) regulations (dynamic regulations and the availability of the National Guidelines for Medical Services has not been fulfilled and there is no standard for readmission and fragmentation), the NHI financing system (inconvenience of the financing system and the adequacy of the INA-CBGs tariff calculation), and the BPJS Health system (inconvenience of the BPJS Health system and the BPJS Health system which makes it difficult).

Conclusions: The causes of health insurance fraud in hospitals can be explained by the gear fraud theory that Internal factors are the main cause and external factors predispose to health insurance fraud in hospitals. These internal and external factors interact with each other like the working mechanism of a gear. Understanding the theory of gear fraud will help formulate fraud prevention efforts in health insurance programs in hospitals that are more comprehensive and focus on eliminating the causes of fraud.