5 common types of fraud in healthcare services
No health facility or healthcare services in the world is completely free from potential fraud. Basically, fraud occurs due to opportunity,rationalization, and motivation. In Indonesia, the Social Security Administration (BPJS) as the organizer of the National Health Insurance (JKN) is not free from fraudulent practices.
Fraud and its Impact
This fraud is allegedly one of the factors that BPJS continues to experience a deficit, which until 2018 is estimated to reach Rp 16.5 trillion. In addition to deficits, fraud also creates moral hazard for the community as service recipients.
Who is the culprit?
Potential health service fraud can come from many parties; not only BPJS personnel, but also goods and services providers, hospitals, or even the participants themselves. This diversity of fraud sources shows how complex this problem is and the need for a comprehensive approach in its prevention efforts.
Types of Potential Fraud in Health Services
Typically, there are five common types of fraud that occur in healthcare services, which are:
1. Upcoding
Diagnosis and service codes are made more complex than what is actually done. For example, a patient with type 2 DM is coded with type 2 DM with various complications, resulting in higher service rates.
2. Phantom billing
A health facility bills for a service that does not actually exist.
3. Inflated bills
Actions that make bills at health facilities inflated.
4. Cancelled service
Canceling a service, but the service is still billed.
5. Unnecessary treatment
Health facilities perform health services that patients do not need. For example, a patient has to have an appendectomy when they don’t need it.
Fraud Prevention Methods
What are the methods for preventing fraud?
Fraud prevention in healthcare encompasses a range of strategic measures aimed at reducing the risk of fraudulent activities. One key method is the implementation of supervision and verification processes. For instance, establishing a multi-tiered system that verifies patient information at each step of the service, from registration to billing claims. Verifying the patient’s identity during registration is one way to confirm that the card being used is legitimate and not fraudulent.
Another approach is the implementation of a reporting system or whistleblowing system. This system provides a safe and confidential channel for employees, patients or other concerned parties to report suspicious or fraudulent activity without fear of retaliation. The whistleblowing system should be designed to protect the identity of the whistleblower and ensure the confidentiality of the report. Implementation of this system can increase transparency and encourage prompt reporting of fraudulent practices, allowing corrective actions to be taken more quickly.
And last but not least, provide continuous education. Education and training for employees on the risks of fraud and ways to prevent it is essential. This training program should include information on work ethics, fraud detection, and reporting procedures. By raising employee awareness about the impact of fraud and how to report it, organizations can create a strong culture of integrity.