Saikhu, Saikhu and jati , Sutopo Patria and Sugiharto, J (2017) Analisis Faktor – Faktor Yang Mempengaruhi Potensi Terjadinya Fraud Klaim Pada Program Jaminan Kesehatan Nasional Di RSUD Dr. H Soewondo Kendal. Masters thesis, UNIVERSITAS DIPONEGORO.
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Abstract
Universitas Diponegoro Fakultas Kesehatan Masyarakat Program Studi Magister Ilmu Kesehatan Masyarakat Konsentrasi Administrasi Rumah Sakit 2017 ABSTRAK Saikhu Analisis Faktor – Faktor Yang Mempengaruhi Potensi Terjadinya Fraud Klaim Pada Program Jaminan Kesehatan Nasional Di RSUD Dr. H Soewondo Kendal xviii +97 halaman + 11 tabel + 5 gambar + 6 lampiran Penulisan resume medis yang tidak dilengkapi oleh dokter segera setelah pasien dilayani dan dirawat di rumah sakit umum dr. H. Soewondo Kendal dapat berpotensi terjadinya kekeliruan pada pengkodingan untuk klaim. Persoalan lain tentang perbedaan tarif antara tarif rumah sakit berdasarkan peraturan bupati dan besaran klaim sesuai tarif INA-CBGs yang terpaut jauh pada beberapa kasus penyakit diduga juga turut memicu potensi terjadinya fraud. Tujuan dari penelitian ini untuk mengungkapkan faktor – faktor yang mungkin dapat memicu potensi terjadinya fraud di rumah sakit dr. H. Soewondo Kendal Metode penelitian yang digunakan adalah jenis penelitian deskriptif dengan cara observasi dilanjutkan dengan focused group discussion (FGD) untuk menentukan prioritas yang paling memungkinkan munculnya potensi terjadinya fraud dan diteruskan dengan wawancara mendalam. Penelitian ini melibatkan 5 informan utama dan 2 informan triangulasi. Didapatkan 3 potensi terjadinya fraud yaitu: fragmentasi pelayanan (unbundling), upcoding dan self referal yang ditinjau dari 3 aspek yaitu opportunities, preasure, dan razionallization. Hasil penelitian menunjukkan bahwa terdapat belum maksimalnya pengawasan dan pengendalian ditiap tahapan pelaksanaan pelayanan pasien peserta BPJS Kesehatan. Ditemukan adanya kebijakan yang berpotensi menimbullkan potensi terjadinya fraud. Terdapat disparitas yang tinggi antara tarif yang berlaku berdasarkan peraturan bupati dengan tarif klaim InaCBGs yang juga berpotensi terjadinya fraud. Sistem pengkodingan diagnosa dan tindakan berdasarkan ICD-9 dan ICD-10 belum dipahami dengan baik oleh dokter yang menangani pasien. Rekomendasi dari penelitian ini adalah perlu dibentuknya tim pengendali Fraud. Kebijakan pelayanan pasien disesuaikan dengan kebijakan sistem Jaminan Kesehatan Nasional (JKN). Mengusulkan evaluasi tarif InaCBGs ke kementrian kesehatan setiap akhir tahun. Mengadakan pelatihan tentang penerapan ICD-9 dan ICD-10 bagi staf medis. Kata Kunci : Fraud, upcoding, self referral dan fragmentasi Kepustakaan : 38 (1995 – 2016)Diponegoro University Faculty of Public Health Master’s Study Program in Public Health Majoring in Hospital Administration 2017 ABSTRACT Saikhu Analysis of Factors Influencing the Potency of Fraudulent Claims in the National Health Insurance Program at Dr. H. Soewondo Public Hospital in Kendal xviii + 97 pages + 11 tables + 5 figures + 6 appendices Writing a medical summary that was not completed by a physician soon after providing services and treatment to patients at Dr. H. Soewondo Public Hospital in Kendal had a potency to make mistakes in coding for claim. Another problem was a big tariff difference for some diseases between the tariff of a hospital based on regent’s regulation and amount of claim based on the tariff of INA-CBGs that could trigger a potency of fraud. This study aimed at identifying factors that were potential to allow fraud to occur at Dr. H. Soewondo Public Hospital in Kendal. This was a descriptive study conducted by observing followed by Focus Group Discussion (FGD) to determine a priority that could trigger a potency of fraud and indepth interview. This study involved 5 main informants and 2 informants for triangulation purpose. There was three potencies that could lead to fraud namely unbundling, upcoding, and self-referral viewed from three aspects namely opportunity, preasure, and rasionalisation. The results of this study showed that monitoring and controlling in each step of implementation of patients who were BPJS members were not optimal. There was found some potencies that might lead to fraud. There was big difference between the tariff based on the regent’s regulation and the tariff of claim based on INA-CBGs that might allow fraud to occur. A coding system of diagnosis and action based on ICD-9 and ICD-10 had been well understood by physicians who provided treatment to patients. A team of fraud control needs to be formed. A policy of patients’ services needs to be adjusted with a policy of a National Health Insurance system. The tariff of INA-CBGs needs to be proposed to Ministry of Health in order to be regularly evaluated in the end of year. In addition, training of ICD-9 and ICD-10 implementation for medical staffs needs to be conducted. Keywords : Fraud, Upcoding, Self-Referral, Fragmentation Bibliography: 38 (1995-2016)
Item Type: | Thesis (Masters) |
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Subjects: | Q Science > Q Science (General) |
Divisions: | School of Postgraduate (mixed) > Master Program in Public Health |
ID Code: | 53808 |
Deposited By: | INVALID USER |
Deposited On: | 23 May 2017 08:38 |
Last Modified: | 23 May 2017 08:38 |
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