Recognizing Hospital Fraud and Abuse: Claim Analysis of Social Health Insurance Enrolees in Indonesia

Presenter: Andi Afdal, PT Askes (Persero) Indonesia

Abstract

Rationale : In current years, fraud and abuse in the health care service have grown to be the major issues. In many mid-low income countries, like Indonesia, the awareness of protecting the health care spending from moral hazard arouses particularly due to the persisting disequilibrium of revenue and expenditure by year. This may lead as an attractive target in fraud and abuse.

Vulnerability of the health system bothered by moral hazard motives is induced by three main factors: 1) asymmetric information that prevails in the health system; 2) uncertainty in the health markets, when illness will occur and what kinds of illnesses may people get and how effective the medical treatments are; 3) in demand side, the problem of moral hazard may reflect in an increase of the demand for the covered health care since the patients are not fully facing the marginal cost.

The existence of fraud and abuse will make the patients to be in loss for both kinds of patients which are either paid by self (out of pocket) or insured by social health insurance body like PT. Askes (Persero) in Indonesia.

Objectives : The aim of this analysis is to investigate and to recognize the model of fraud and abuse in one sample of hospital, and to seek the appropriate solution for minimizing the cost impact for PT Askes (Persero).

Methodology : The possibility of fraud and abuse is initially detected by analysing data claim. Data on patient treatment during the period of year 2006 up to the early 2007, both for outpatient and inpatient care services in the sample hospital, were elaborated in order to point out the treatment of unit cost, length of stay, total cost, percentage of referral and other relevant indicators. One sample hospital has been pointed out based on the complexity of its health services as well as weight to its health care expenditure.

An in-depth interview was also done to the administrative hospital officer, claim verification officer of PT. Askes (Persero), claim data entry officer, as well as to the patients and doctors. They are selected at random purposive sample in order to see the sights of real activities for claims, which were initially recognized as fraud and abuse.

Results : The study find that 4-14% of monthly expenses are recognized as fraud and abuse. From those ‘black activities’, the amount of IDR 146.9 billions was discovered as potential loss of PT. Askes (Persero). As many as 968 out of 15.196 claims (or 6.4%) were recognized as ‘placebo claim’ fulfilled by fraud and abuse nuances. From those findings, up coding, unbundling, double billing and false claim have been identified as the most frequent type of fraud and abuse. Claims verification was considered as the major filter for preventing from the occurrence of fraud and abuse activities.

Conclusions : Fraud and abuse behaviour is nevertheless always aroused as deceitful modus from health service providers as one of the social health insurance body. The pattern of fraud and abuse actions found on this study can be spread up to all Askes Branches nationwide as early awareness towards the health service provider’s fraud and abuse. Intervention and improving control mechanisms should be taken by PT. Askes (Persero) in order to prevent from significant loss due to fraud and abuse.