International Journal of Public Health Science (IJPHS)

Vol. 12, No. 3, September 2023, pp. 1040~1047

ISSN: 2252-8806, DOI: 10.11591/ijphs.v12i3.22952  1040

Potential fraud and its’ prevention in the implementation of

national health insurance at Dadi Regional Hospital

Amaliah Amriani Amran Saru1, Muhammad Alwy Arifin1, Darmawansyah Darmawansyah1,

Amran Razak1, Muhammad Syafar2, Rahmatia Rahmatia3
1
Department of Health Administration and Policy, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
2
Department of Health Promotion and Behavior Science, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
3
Department of Economic Science, Faculty of Economy, Hasanuddin University, Makassar, Indonesia

Article Info ABSTRACT

Article history: The National Health Insurance program started running in Indonesia on
January 1, 2014. Along with the increasing number of National Health
Received Jan 10, 2023 Insurance participants and health facilities, more criticism has emerged from
Revised May 19, 2023 various parties, including from National Health Insurance providers
Accepted Jun 8, 2023 regarding the alleged fraud. Fraud can have a negative effect on finances, the
standard of medical care, and the perpetrator's reputation. This study's goal
was to assess the likelihood that fraud may occur at Dadi Regional Hospital
Keywords: in Makassar, Indonesia. The study also explored the procedures and policies
in place for preventing the fraud. This qualitative study employed
Fraud prevention phenomenological design. The results of the study show that there is a fraud
National health insurance prevention system at Dadi Regional Hospital in the form of policy and
Prevention team guideline formulation, a culture of prevention, implementation of quality
Hospital control, and cost control. Even though they already have a prevention system
in place, there is still some lack of information being disseminated about the
fraud prevention team established. There are still frequent discrepancies
between the diagnosis code input in the National Health Insurance system
and the patient's diagnosis Hence, the Internal Monitoring Unit is still in the
process of establishing a fraud prevention system.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Amaliah Amriani Amran Saru
Department of Health Administration and Policy, Faculty of Public Health, Hasanuddin University
Makassar, Indonesia
Email: [email protected]

1. INTRODUCTION
In order to realize global commitments, as mandated in the 58th World Health Assembly (WHA)
resolution in 2005 in Geneva, many countries have implemented Universal Health Coverage (UHC) for their
entire populations, including Indonesia. The term “UHC” refers to a concept involving the reform of health
services that covers all communities in terms of accessibility and equity of health services, quality and
comprehensive health services that include preventive, promotive, curative to rehabilitative services and
reduce financial barriers to obtaining health services for every citizen. There are several problems that may
arise in order to realize UHC, one of which is fraud [1]. Fraud is a deliberate attempt to obtain a benefit that
neither individuals nor institutions should have enjoyed, which has the potential to cause indirect harm to
other parties. According to Li et al. the purpose of committing fraud is to get something valueable at the
expense of other people as a fraud attempt to obtain personal gain. All aspects of health services, which can
result in elements of fraud, are related to elements of fraud in the healthcare field [2].

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Int J Public Health Sci ISSN: 2252-8806  1041

The number of cases was obtained from research at several hospitals in Indonesia, Germany,
Malaysia, and Portugal by reviewing medical records and data also obtained from Social Security
Administrative Body (BPJS). Most fraud cases were readmissions, with a total of 4,827 incidents [3]. Thus,
there were 4,600 cases of upcoding. This is similar to the research results from Thompson et al. [4], which
indicated that the most frequent forms were upcoding, phantom billing, and kickbacks. Moreover, in 2015,
there were around 175 thousand claims from health services to BPJS with a value of 400 billion rupiah that
were detected as fraudulent in Indonesia, one million claims have been discovered thus far. According to
Baranek [5], the various types of health service fraud were comprised of ten schemes, which include:
claiming services that were never provided; claiming services that were notcovered by insurance as being
covered by insurance; falsifying service times, locations, and providers; claiming bills services that patients
should pay for; reporting inaccurate diagnoses and incorrect procedures; providing excessive service;
accepting corruption (bribes); and prescribing unnecessary drugs under the national health insurance (JKN)
in Indonesia. The alleged fraud undoubtedly cannot be separated from the implementation of the national
health insurance, which is conducted in an effort to equalize access to health services in Indonesia.
National Health Insurance fraud is an intentional act committed during the implementation of the
health insurance program by the Healthcare and Social Security Agency (BPJS Kesehatan) officers,
participants, health service providers, as well as drug and medical device providers, with the goal of
obtaining financial benefits from the health insurance program in the national social security system through
fraudulent acts that do not comply with the provisions. In addition, fraud is more commonly associated with
secondary (advanced) health care, specifically hospitals [6]. In Indonesia, there are three forms of fraud with
the highest potential, including upcoding, which has the most potential for fraud with a value of 50%; then
there is unbundling, which has a value of 25%; and reading, which has a value of 6% [7]. Indonesian
Corruption Watch (ICW) together with 14 monitoring organizations discovered 49 frauds in the JKN
program committed by government or private hospitals, one of which was related to BPJS Kesehatan bill
claims where the hospital limited hospitalization by diagnosing the patient as not having the disease, They
discovered BPJS patients were always informed if there were hospitalization restrictions of up to 4-5 days,
false claims, excessive medicine and medical equipment bills, or self-referral patients; extending the course
of treatment period may be accomplished in various ways. Meanwhile, drug suppliers frequently do not meet
the needs of medicines and or medical devices [8].
In 2019, the government issued Regulation of the Minister of Health of the Republic of Indonesia
(Permenkes) No. 16 of 2019 concerning the prevention and handling of fraud and the imposition of
administrative sanctions against fraud in the implementation of the health insurance program. The Permenkes
is a revision of the previous anti-fraud regulations. It is only that there are still a number of issues arising
from the inefficiency of BPJS Kesehatan services. Therefore, efforts to prevent fraud are needed to minimize
the potential for and control fraud incidents in health care facilities [9]. According to a report obtained from
one of the BPJS participants at Dadi Regional Hospital in Makassar City, there was an alleged fraud by
health workers by directing BPJS patients to purchase medicines from their pharmacy because the hospital’s
supply of medicines had run out, but even after the patient had purchased the medicine, the patient was still
given the same type of medicine from the hospital as the BPJS claims. This demonstrates that the potential
for fraud remained high at Dadi Regional Hospital in Makassar City that year. In addition, one of the national
health insurance experts stated that the amount of Indonesia Case Based Groups (INA-CBG) rates that
hospitals receive in the JKN era has the potential to lead to fraud.
According to research conducted by Matloob et al. [10], hospitals have a tendency to make
fraudulent claims due to the absence of a fraud prevention system, the absence of sanctions against fraud
perpetrators, the lack knowledge among coders regarding disease coding and procedures in accordance with
INA CBGs, and the lack of understanding among medical staff regarding the INA-CBG payment system. For
this reason, further research is needed to investigate the susceptibility of health providers to committing fraud
in the implementation of national health insurance. Previous studies conducted at Dadi Regional Hospital in
Makassar City discovered that the implementation of clinical pathways that have not been carried out
optimally has led to discrepancies amongst doctors in how they administer medicines, which has an impact
on the expenses that BPJS must pay. Based on the aforementioned description, health care facilities are
parties with a high potential for committing fraud. Therefore, the authors were interested in conducting
research on the analysis of fraud potential in the implementation of national health insurance at Dadi
Regional Hospital in Makassar City and an in-depth investigation of the stakeholders needed to create a
hospital fraud prevention team. It is necessary to regulate anti-fraud policies by analyzing the possibility of
fraudulent activity in health care facilities. There should be an anti-fraud monitoring team to prevent health
workers at health care facilities from engaging in fraud [11].

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2. METHOD
This study used a qualitative method with a phenomenological design to explore the experiences and
awareness of the research subjects. In this study, the authors investigated what research informants experienced,
heard, saw, and thought about their daily experiences with the implementation of the national health insurance
program at a hospital. It was intended that by doing this investigation, the underlying causes of the fraud
phenomenon would be clearly explained and preventative solutions to address them would be obtained. This
study made reference to the fraud hexagon theory proposed by Vousinas [12] and the Regulation of the Minister
of Health of the Republic of Indonesia (Permenkes) No.16 of 2019 concerning the Fraud Prevention System.
These two references have become a standard measure of the potential for fraud at Dadi Regional Hospital in
Makassar City by examining the variables listed as follows: i) ability as determined by the position occupied at
the job; ii) pressure, iii) formulation of policies and guidelines, iv) prevention culture, v) hospital cost control
and quality control; vi) formation of a fraud prevention team.
The purposive sampling method was used to select research informants. This method allowed for the
contact of several potential informants, who were then asked whether they knew other people who met the
characteristics intended for research purposes. The informants in this study were two people from the hospital’s
internal supervisory unit (SPI), 2 BPJS coders, 1 BPJS verifier, 1 specialist doctor, 1 hospital public relations
officer, 1 pharmacist, and 2 BPJS patient families. Only those informants related to policy implementation were
interviewed in accordance with the research objectives.
These informants are a significant component since they supervise and participate most in the
implementation of the national health insurance fraud prevention policies in hospitals. In this case, each of the
informants plays different roles, such as coders, who play an important role, especially for coding INA-CBG;
clinicians (specialist doctors) as parties who deal directly with patients; BPJS verifiers, whose job it is to verify
hospital BPJS claims; the hospital’s internal supervisory units as supervisors in the JKN implementation
process; pharmacists as parties who participate in program implementation; as well as a hospital public relations
officer and patient families to add to the amount of information gathered from program implementation at Dadi
Regional Special Hospital in Makassar City. The informants provided written informed consent and that the
study protocol was approved by the institute's committee for human research. This study has received
approval from the Health Research Ethics Commission (HREC) of the Faculty of Public Health, Hasanuddin
University, with protocol number: 01322012036 and letter number: 2503/UN4.14.1/TP.01.02/2022.
Furthermore, when conducting qualitative research, both primary and secondary data were collected. The data
obtained from the results of the interviews were then analyzed using the content analysis method. In addition,
the authors triangulated the data to ensure that the information collected was accurate.

3. RESULTS AND DISCUSSION

In-depth interviews and document reviews conducted at the Dadi Regional Hospital in Makassar
City based on the fraud hexagon theory and Regulation of Minister of Health of the Republic of Indonesia
(Permenkes) No. 16 of 2019 concerning the Fraud Prevention System showed that the hospital already has a
fraud prevention system. However, there are still some inadequacies in the system’s implementation as
shown in Table 1.
Tabel 1 shows the analysis of research results based on informant statements. Thematic analysis was
used to examine informants’ statements to find compatibility between the theory and the regulation of the
Minister of Health regarding fraud prevention and program implementation at Dadi Regional Hospital in
Makassar City. The results of the research and analysis are described as follows.

3.1. Ability
The informant’s ability can be determined by the influence of the informant’s position on the
informant’s potential to commit fraud. Based on the results of the content analysis of the interviews
conducted, it is known that every informant involved in the implementation of the national health insurance
(JKN) at the Dadi Regional Hospital in Makassar City had the ability to commit fraud but chose not to do so.
The informant chose to cultivate the work ethics outlined in Dadi Regional Hospital’s rules in Makassar City.
Ethics can be defined as the agreed-upon standards of what is desirable and undesirable conduct, as well as
the right and wrong behavior of an individual, group, or entity. Individual ethical values are influenced by
behavior and what is perceived as right or wrong. Therefore, having high ethical standards (competence,
confidence, and professionalism) will decrease the possibility of employees engaging in fraudulent behavior
while performing their duties [13]. This demonstrates that, despite the fact that anyone can commit fraud,
individual ethics have a big impact on preventing it.

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3.2. Pressure
Fraud is a result of pressure, including financial pressure, bad habits, and other harmful habits,
depending on individual conditions [14]–[16]. This study showed that the informants, particularly coders and
verifiers, did not experience any pressure as they carried out their duties due to the hospital’s lack of
supervision. This is obviously contradictory because periodic monitoring is needed to ensure the service
process complies with the rules. Internal control for preventing fraud in companies has an effect that can
result in a decline in the performance of service companies such as hospitals, as well as in manufacturing
companies and the general performance of the national economy. The creation of effective management
within a company or organization can be a strength for the long-term sustainability of the business itself.
According to Mackey et al. [17], internal controls and information systems can be used to identify, analyze,
and communicate organizational events. The organization will become strong and successful when its control
and management are conducted properly. Meanwhile, weak internal control in an organization can lead to
various frauds. This demonstrates how crucial internal control is in protecting companies against fraud and
abuse [18], [19].

Table 1. Analysis of potential fraud at Dadi Regional Hospital in Makassar City based
on fraud theory and Permenkes
Fraud prevention system in the health
Implementation at Dadi Regional Hospital in Makassar City Conclusion
insurance program
Ability
The effect of position on potential fraud Every part and person involved in the implementation of No effect
JKN at Dadi Regional Hospital in Makassar City has the
opportunity to commit fraud but instead chooses not to do
so and upholds the work ethics that have become the
institution’s rules.
Pressure
Dissatisfaction with organizational According to informants at Dadi Regional Hospital in No effect
systems and workload Makassar City, due to the lack of hospital supervision,
coders and verifiers in particular did not feel excessive
pressure to perform their duties.
Formulation of policies and guidelines
The implementation of fraud prevention A decree has been issued at the Dadi Regional Hospital in Correspond
policies with the principles of good Makassar City regarding the duties and authorities of the
corporate and good clinical governance. fraud prevention team, in this case, the hospital’s internal
supervisory unit, and the application of clinical pathways;
however, the implementation of this policy still needs to be
improved.
The establishment of fraud risk Fraud risk management at Dadi Regional Hospital in Correspond
management guidelines. Makassar City is guided by the regulation of the Minister of
Health as well as several additional guidelines tailored to the
needs of the hospital.
Culture of fraud prevention
Establishing a culture of integrity, The culture implemented by Dadi Regional Hospital in Correspond
ethical values, and standards of Makassar City includes providing patients with proper
behavior and educating all parties diagnoses, upholding ethical values, and double-checking
related to health insurance about anti- the files that will be claimed by the coder. However,
fraud awareness specialized training for fraud prevention (inadequacy) is still
offered infrequently at Dadi Regional Hospital in Makassar
City.
Quality control and cost control
The formation of a quality control and Dadi Regional Hospital in Makassar City has a quality Correspond
cost control team control and cost control team that is appointed by BPJS
The implementation of the concept of Dadi Regional Hospital in Makassar City has implemented Correspond
quality control management in health service standards, monitoring and evaluation, coordination
services establishment, and service improvement.
Fraud prevention team
The formation of a fraud prevention Dadi Regional Hospital in Makassar City has formed a fraud Correspond
team that is tailored to the needs of the prevention team based on regulations from local regulation
hospital (PERDA) and the regulation of the Minister of Health in the
form of a hospital’s internal supervisory unit. Furthermore,
it is necessary to form a special team with the responsibility
of preventing potential fraud, especially when national
health insurance is implemented in the hospital
Source: Primary Data, 2022

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3.3. Policies and guidelines

The formulation of policies and guidelines was guided by concepts and principles that served as the
framework and basis of plans for the implementation of fraud prevention with the principles of good
corporate governance and good clinical governance. The formulation of policies is essential as the underlying
principle of a management process and mechanism based on statutory regulations for the prevention of fraud
in the implementation of the national health insurance program. The Dadi Regional Hospital in Makassar
City has formulated and implemented guidelines in accordance with the needs of the hospital, which are
strongly attributable to both local regulations and the regulation of the Minister of Health. According to the
authors’ analysis of the documents related to the management of the policies and guidelines that are being
implemented in hospitals, additional socialization is required for the policies that have been formed.
The authors also discovered that the implementation of the policy had not gone well because several
informants reported that the fraud prevention team had only been formed as a formality and that its members
had continued to work in accordance with their respective fields as before the decree on fraud prevention was
issued, despite the fact that the team had been formed. It has not been possible to prevent fraud effectively,
one of the reasons for fraud is the inadequacy of socialization regarding fraud prevention policies [20].
Furthermore, fraud may also result from miscommunication between the coder and the doctor in charge of
service (DPJP), as well as the BPJS verifiers’ problems with an uncoordinated fraud prevention system and
the absence of strict sanctions for fraud. As a result, it is highly recommended that Dadi Regional Hospital in
Makassar City regularly conduct hospital policy socialization for all parties involved in the implementation
of the national health insurance [21], [22].

3.4. Culture of prevention

Culture is a developed way of life that a group of people share and that is passed down from
generation to generation. The implementation of a professional code of ethics and standards of behavior to
achieve institutional goals is a standard for measuring potential for fraud in an analysis of the potential for
fraud based on the prevention culture at Dadi Regional Hospital Makassar City. According to the informant,
the coordination and adherence to ethical and professional values when diagnosing, as well as double-
checking the results of the diagnosis to prevent fraud, were important components of the culture performed.
Based on the research results, there are still frequently discrepancies between the diagnosis code entered into
the national health insurance system and the patient’s diagnosis, but this is not yet regarded as fraud because
the coding team continues to coordinate with the BPJS, the agency that provides the national health insurance
service, and the internal supervisory unit is still in the process of creating a fraud prevention system. This
demonstrates that the culture of prevention has been properly implemented through coordination and
supervision. Moreover, upcoding refers to the possibility of fraud occurring in hospitals as a result of
inaccurate coding. Upcoding is not necessarily considered fraud; there must be an element of intent to earn
financial gain. Upcoding can increase the value of claims [23]–[25].
According to research conducted by Timofeyef and Mihajlo [26], organizational culture has a
significant effect on fraud prevention. Organizational culture may also be used as a management tool to
achieve efficiency, effectiveness, productivity, and work ethic, as shown in various companies in Japan, the
United States, and other European nations. It turns out that this can effectively help companies succeed.
Furthermore, based on the research results, it is known that socialization about the risks and methods for
preventing fraud is still infrequently conducted at Dadi Regional Hospital in Makassar City. Meanwhile, it is
necessary to cultivate this in order to routinely educate employees about the negative effects of fraud and the
significance of putting a professional code of ethics in place. Uneven socialization among all coders may lead
to fraud by enabling coders to encode the diagnosis of patients in a way that does not comply with the rules
[27]. In addition, fraud can occur as a result of employees’ dishonesty regarding their health, such as
manipulating the birth weight of babies to get higher costs [28].

3.5. Quality control and cost control

The hospital has formed an internal team for quality control and cost control. In addition to this
team, a quality control and cost control team was also formed by the BPJS and professional organizations.
The implementation of quality control and cost control has resulted in the socialization of the authority of
health workers in the performance of their duties, the implementation of monitoring and evaluation service
standards, the writing of complete and clear medical records, the maintenance of claims procedures, the
execution of clinical audits, and the implementation of quality management concepts. In order to anticipate
the spread of fraud in the health sector, the government of Indonesia, through the Ministry of Health, issued
Regulation of the Minister of Health No. 36 of 2015 concerning Prevention of Fraud in the Implementation
of the Health Insurance Program in the National Social Security System. Moreover, a national health
insurance (JKN) fraud prevention team was established at the advanced referral level health facilities, and

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evidence-based information technology was used to construct service-oriented quality control and cost
control. The fraud prevention team is responsible for detecting potential fraud through the analysis of claim
data [29]. However, Wibowo et al. [30] stated that the detection of potential fraud is currently done manually
by comparing an allegation of fraud with the regulations issued by the Ministry of Health and the BPJS
Kesehatan.

3.6. Formation of a fraud prevention team

In order to optimize fraud prevention, it is considered very important in every hospital to form a
fraud prevention team as one of the controls under the Regulation of the Minister of Health No. 16 of 2019.
There is currently no fraud prevention team at Dadi Regional Hospital in Makassar City; instead, this
responsibility is under the authority of the hospital’s internal supervisory unit. The only obstacle encountered
while carrying out its duties and functions was a discrepancy in the time scheduled for meeting the person to
be supervised. It is necessary to form a fraud prevention team at Dadi Regional Hospital in Makassar City. In
addition, based on the expectations of the informants, the team will later consist of representatives from the
hospital program department, hospital finance, BPJS as the national health insurance distribution agency, and
the legal or academic division.

4. CONCLUSION
The study revealed that Dadi Regional Hospital has implemented a fraud prevention system in the
implementation of the national health insurance, in this case in collaboration with the BPJS, in the form of
policy and guideline formulation, a culture of prevention, quality control implementation, and cost control.
Even though the hospital already has a fraud prevention system, there are still some inadequacies in its
implementation, including a lack of socialization regarding the fraud prevention team (internal supervisory
unit); the fact that there are still frequently discrepancies between the diagnosis codes entered into the
national health insurance system and the patient’s diagnosis, but this does not include fraud because the coder
team continues to coordinate with the BPJS as the national health insurance service provider agency; and the
implementation of the clinical pathway policy, which created obstacles in several parts of the service.
Furthermore, the authors offer some suggestions for this hospital. The suggestions are to form a specific team
for preventing health insurance fraud, consisting of representatives from the hospital program department,
hospital finance, BPJS as the national health insurance distribution agency, and the legal or academic
department.

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BIOGRAPHIES OF AUTHORS

Amaliah Amriani Amran Saru is a student of the master program

(postgraduate program) at Faculty of Public Health, Hasanuddin University, focus on the
fields of administration and health policy. She participated in several research activities with
lecturers at the Faculty of Public Health while studying. She published three journal articles,
one of as the main author. She can be contacted at email: [email protected].

Muhammad Alwy Arifin was born in Makassar, South Sulawesi. He completed

his bachelor's degree at the Faculty of Social and Political Sciences, Hasanuddin University
in 1988. Then he earned his master's degree at the Airlangga University Postgraduate in 1995
in the field of IKM-Health Administration. He serves as a teaching staff in the Department of
Health Administration and Policy. The competence that he mastered was in the field of
Health Financing Administration. He can be contacted at email: [email protected].

Int J Public Health Sci, Vol. 12, No. 3, September 2023: 1040-1047
Int J Public Health Sci ISSN: 2252-8806  1047

Darmawansyah was born in Makassar, South Sulawesi. He successfully

completed his bachelor's degree at the Faculty of Economics, Hasanuddin University in 1988.
Then earned his master's degree at the Postgraduate Faculty of Hasanuddin University in the
field of Resource Economics/Development Economics & Planning in 1993. Then he
continued his doctoral degree in Economics/Health Economics at PPs UNHAS in 2004.
Competency which he mastered is the field of Health Economics. He can be contacted at
email: [email protected].

Amran Razak was born in Makassar, South Sulawesi, completing his bachelor's
degree at the Faculty of Economics, Unhas in 1983. Then he earned his master's degree at the
UI Postgraduate Faculty in Health Planning & Management in 1990. After that he continued
his doctoral degree in Economics at PPs UNHAS in 2004. He also had served as Assistant to
the Chancellor for Student Affairs (Echelon I/b) at Hasanuddin University for the 1997-2001
period and has now become a Professor of FKM Unhas and has served as a teaching staff in
the Department of Health Administration and Policy FKM Unhas since 1986. Competence
mastered is an expert in the field Health Insurance. He can be contacted at email:
[email protected].

Muhammad Syafar was born in Makassar October 21, 1955. He graduated

from Medicine at Hasanuddin University in 1987, earned a master's degree at Airlangga
University in 2001, and a doctorate at Hasanuddin University in 2006. He is a Professor at
Hasanuddin University focusing on Health Promotion and Behavior Science. He can be
contacted at email: [email protected].

Rahmatia is a lecturer on Faculty of Economy Hasanuddin University. Apart

from being a lecturer at Faculty of Economics, she is also active as a research advisor at the
Faculty of Public Health, especially related to the health financing system and the national
social security system. She can be contacted at email: [email protected].

Potential fraud and its’ prevention in the implementation of national … (Amaliah Amriani Amran Saru)