bprs upaya pencegahan fraud lampung 06-8-2016

8/18/2019 Bprs Upaya Pencegahan Fraud Lampung 06-8-2016

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1

UPAYA PENCEGAHAN FRAUDDALAM PELAKSANAAN JKN DI RUMAH SAKIT

TIMBADAN PENGAWAS RUMAH SAKIT (BPRS) INDONESIA

KEMENTERIAN KESEHATAN RI

Disampaikan pada Acara Sosialisasi Badan Pengawas Rumah Sakit Provinsi Malu

Ambon , Tgl. ! " # Maret $%&


2/22

Materi

1. DEFINISI FRAUD2. TUJUAN PENCEGAHAN FRAUD

3. JENIS JENIS FRAUD

4. KEBIJAKAN DAN PEDOMAN PENCEGAHAN FRAU


3/22

Defnisi Fr!" :

1. Fr!" a!a" Pr#$ra" Ja"i%a% Ke&e'ata% (aa Si&te" Ja"i%a%

S#&ia! Na&i#%a! aa!a' U#$ $n% se&r sen%' "i!n

"en%n *en&i#+n s!+! e!n+!n%n $n% +i" se,r!sn$

"ini*+i -e, in"i.i"! +! ins+i+!si "en%n *er!%in #i,

in/

2. A0!se "er)(a*a% Pe%$$)%aa% Pr#&e)r Dia$%#&ti* ata)

Tera(i a!a" Pr#$ra" Ja"i%a% Ke&e'ata% Paa Si&te" Ja"i%a% S#&ia! Na&i#%a! +a%$ tia* ,era&ar*a% I%i*a&i Mei&

+a%$ Re!e-a% tia* "e"i!i*i B)*ti I!"ia' a% E/e*ti0ta& +a%$

)*)( ata) tia* Cost – Efective.

3


4/22

T))a% U(a+a (e%e$a'a% ite"(at*a% a!a" K#%te*& :

1. Paa tata *e!#!a Or$a%i&a&i +a%$ Bai* (Good Corporate

Govermance)

2. Paa tata *e!#!a Pe!a+a%a% K!i%i& +a%$ Bai* (Good Clin

Govermance)

3. Paa *e%a!i M)t) a% *e%a!i Bia+a Pe!a+a%a% R)"a'

Sa*it

KMKB

4


5/22

JENIS FRAUD 1

A/ PIHAK YANG BERPOTENSI MELAKUKAN FRAUD 1

1. Fra) #!e' Pe&erta

2. Fra) #!e' BPJS Ke&e'ata%

3. Fr!" -e, Fsii+s Pe$nn Kese,+n(R!*,

4. Fra) #!e' Pe%+eia O,at a% A!at Ke&e'ata%

5. Fra) #!e' A&)ra%&i +a%$ "e!a*)*a% F)%$&i K##ri%a&i M

B/ Fr!" -e, Fsii+s Pe$nn Kese,+n *ei#!

1. Je%i& Ti%a*a% Fra) i FKTP

2. Je%i& Ti%a*a% Fra) i FKT6

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6/22

/ /FKTP

2/2/ Me*n3+n "n #i+si "n i* ses!i "en%n

e+en+!n #er+!rn #er!n"n%4 !n"n$n% 0er!5

2/6/ Me*ni#!si Ki* #" #e$nn $n"i0$r se&r n-n

#i+si52/7/ Meneri* -*isi +s r!'!n e FKTL5

2/8/ Menri 0i$ "ri #eser+ $n% se,r!s+e, +er'*in

"* 0i$ #i+si "n9+! n-n #i+ses!i "en%n


7/22

B/6/ JENIS FRAUD DI FKTL DI RS

2.1. Pe%)!i&a% *#e ia$%#&i& +a%$ ,er!e,i'a% u

2.2. Pe%i(!a*a% *!ai" ari (a&ie% !ai% cloning);

2.3. K!ai" (a!&) phantom billing);2.4. Pe%$$e!e",)%$a% ta$i'a% #,at a% a!*e& in

2.5. Pe"ea'a% e(ie (e!a+a%a% services unbu

ragmentation);

2.7. R))*a% &e") sels-reerals);2.8. Ta$i'a% ,er)!a%$ repeat billing);

2.9. Me"a%i()!a&i !a"a (eraata% length o sta

2.;. Me"a%i()!a&i *e!a& (eraata% tpe o room

2.1


8/22

(standard ocare);

2.13. Me!a*)*a% ti%a*a% (e%$#,ata% +a%$ ti(unnecessar treatment);

2.14. Me%a",a' (a%a%$ a*t) (e%$$)%aa%-e%ti!at#r=2.15. Tia* "e!a*)*a% -i&ita&i +a%$ &e'ar)&%+(phantom

visit);2.17. Tia* "e!a*)*a% (r#&e)r +a%$ &e'ar)&(phantom

procedures);2.18. A"i&i +a%$ ,er)!a%$ (re-admisi);2.19. Me!a*)*a% r))*a% (a&ie% +a%$ tia* &e&e%$a%

t))a% )%t)* "e"(er#!e' *e)%t)%$a% t


9/22

PENJELASAN JENIS FRAUD DI RS

• "pcoding "er)(a*a% (e%$),a'a% *#eia$%#&i& a%?ata) (r#&e)r "e%ai*#e +a%$ "e"i!i*i tari/ +a%$ !e,i'ti%$$i ari +a%$ &e'ar)&%+a.

• #loning "er)(a*a% K!ai" +a%$ i,)ate%$a% ara "e%+a!i% ari *!ai" (a&ie!ai% +a%$ &)a' aa.

• $hantom billing "er)(a*a% K!ai" ata&!a+a%a% +a%$ tia* (er%a' i,eri*a%.

• %nated bills "er)(a*a% K!ai" ata&,ia+a #,at a%?ata) a!at *e&e'ata%+a%$ !e,i' ,e&ar ari ,ia+a +a%$


10/22

& 'ervices unbundling or ragmentation "er)(a*a% K!ai" ata& )aata) !e,i' ia$%#&i&a%?ata) (r#&e)r +a%$ &e'ar)&%+a "e%ai &at) (a*et (e!a+a%a%a!a" e(ie +a%$ &a"a ata) "e%a$i'*a% ,e,era(a (r#&e)r

&eara ter(i&a' +a%$ &e'ar)&%+a a(at ita$i'*a% ,er&a"a a!a",e%t)* (a*et (e!a+a%a% )%t)* "e%a(at*a% %i!ai K!ai" !e,i' ,e&a(aa &at) e(ie (eraata% (a&ie%

@ 'el-reeral "er)(a*a% K!ai" ata& ,ia+a (e!a+a%a% a*i,at r))*a% a!a" r)"a' &a*it ata) r))*a% *e #*ter +a%$ &a"a i /a&i!ita&*e&e'ata% !ai% *e)a!i e%$a% a!a&a% *#"(ete%&i a%?ata) /a&i!ita

@ epeat billing "er)(a*a% K!ai" +a%$ i)!a%$ (aa *a&)& +a%$ &a"

@ ength o sta "er)(a*a% K!ai" ata& ,ia+a (e!a+a%a% *e&e'ata%+a%$ !e,i' ,e&ar a*i,at (er),a'a% !a"a 'ari (eraata% i%a(=

1<


11/22

(e!a+a%a%*e&e'ata% +a%$ !e,i' ,e&ar a*i,at (er),a'a% !a"

'ari(eraata% i%a(=

@ *pe o room charge "er)(a*a% K!ai" ata& ,ia+a(e!a+a%a%

*e&e'ata% +a%$ !e,i' ,e&ar a*i,at (er,eaa%*e!a& (eraata%=

@ Cancelled service "er)(a*a% K!ai" ata& ia$%#&

a%?ata)ti%a*a% +a%$ tia* ai i!a*&a%a*a%=

@ +o medical value "er)(a*a% K!ai" ata& ti%a*a%+a%$ tia*

,era&ar*a% *e,)t)'a% ata) i%i*a&i "ei&=


12/22

& 'tandard o care "er)(a*a% K!ai" ata& ia$%#&i& a%?ata)ti%a*a%

+a%$ tia* &e&)ai e%$a% &ta%ar (e!a+a%a%=

@ "nnecessar treatment "er)(a*a% K!ai" ata& ti%a*a% +a%$

tia*i(er!)*a%=

@ Me%a",a' (a%a%$ a*t) (e%$$)%aa% -e%ti!at#r "er)(a*a%K!ai"

+a%$ !e,i' ,e&ar a*i,at (e%a",a'a% !a"a (e%$$)%aa%-e%ti!at#r

+a%$ tia* &e&)ai e%$a% *e,)t)'a%=

@ $hantom ,isit "er)(a*a% K!ai" ata& *)%)%$a% (a&ie% (a!&)

@ $hantom $rocedure "er)(a*a% K!ai" ata& ti%a*a% +a%$ ti(er%a' i!a*)*a%=

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13/22

@ $hantom $rocedure "er)(a*a% K!ai" ata& ti%a*a% +a%$

tia*

(er%a' i!a*)*a%=

& readmisi "er)(a*a% K!ai" ata& ia$%#&i& a%?ata)

ti%a*a%ari &at) e(ie +a%$ iraat ata) i*!ai" !e,i' ari &at

*a!i

&e#!a' #!a' !e,i' ari &at) e(ie.

@ Me"a%i()!a&i ta%$$a! (e!a+a%a% aa!a' "e%atat ta%$$a(e!a+a%a% tia* &e&)ai *e%+ataa%.

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14/22

KEBIJAKAN DAN PEDOMAN PENCEGAHFRAUD DI RS 1


15/22

2/ PENGEMBANGAN PEDOMAN 1Merie< #e"-*n4#e"-*n $n% s!", " !n+! *en%,si

#e"-*n4#e"-*n r!*, si+=n+r in se0%i 0eri!+1

• Pe"-*n K-"in%

• Pe"-*n A"*inis+rsi i* BPJS

• Pe"-*n Ken"i M!+!

• Pe"-*n Bi$

• Pe"-*n Keen%#n Re* Me"i Psien

• Pe"-*n Te, Ki*

• Pe"-*n Pen$!s!nn Pr+i Kini "n A!r Penn%nn Kini

(Cini& P+,


16/22

2. PEMBENTUKAN TIM PENCEGAHAN FRAUD Ti" Pe%e$a'a% Fra) i,e%t)* i tia( r)"a' &a*it ? FKT6 e%$a% /)%$

(e%e$a'a% /ra) "e!a!)i t)$a&t)$a& ,eri*)t:

6/2/ Te, +er,"# #-+ensi 3r!" (re" >%)= )%t)* "e%i!ai

*e&e&)aia% a%tara &ta%ar (e!a+a%a% e%$a% /a*ta (e!a+a%a%.

Te!aa'a% i%i i!a*)*a% ter'aa( &e!)r)' a&(e* (e!a+a%a% a%

*e)a%$a% ter*ait (#te%&ia! /ra) ter&e,)t. Ha&i! te!aa' ter'aa(

(#te%&ia! /ra) i%i ,ia& ,er)(a tia* aa "a&a!a' ata)

iter)&*a% *eta'a( i%-e&ti$a&i )$aa%.

6/6/ In.es+i%si "!%n e%$a% "e!a*)*a% (e",a'a&a% ata& *!ai" +a%

atata% ,iara*a% *!ai"

)%t)* (er,ai*a% *!ai" ata& )$aa% ? *e")%$*i%a% /ra).


17/22

Ln'!+n 1

6/7/ Pe#-rn ,si= +a%$ i,)at #!e' ti" (e%e$a'a% /ra)

&ete!a' "e"(er#!e' 'a&i! i%-e&ti$a&i )$aa%. Catata% (aa

(e!a(#ra% aa!a' ,)*a% Fra) ata) "e"(er*)at i%i*a&iFra).

6/8/ S-siissi #e#-rn ,si +e, #-+ensi 3r!" (aa

&e!)r)' (er%i! i%ter%a! r)"a' &a*it ari )%it)%it ter*ait

)%t)* *ee!a&a% te%ta%$ )$aa% /ra) a% (e%e$a'a%/ra).

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18/22

7/ SOSIALISASI PENCEGAHAN FRAUD 1

Di!n -e, Ti* Pen&e%,n Fr!" r!*, si+

/#r)"/#r)" (erte")a% i%ter%a! e%$a% &ta/ *!i%i& a

&ta/re*a" "ei* &ta/ *e)a%$a% a% (i'a* ter*ait !ai%%+

Disnn #" s+:

,ai* (aa &aat (er")!aa% ,er!a*)%+a )(a+a (e%e$a'a

*eti*a ite")*a% ,e%t)*,e%t)* terte%t) )$aa% /ra)

a% (e!a(#ra% 'a&i! te!aa' ter'aa( (#te%&ia!

"e"a%ta(*a% )(a+a (e%e$a'a% /ra) &eara ,er*e!a%

8 PEMBINAAN DAN PENGAWASAN


19/22

8/PEMBINAAN DAN PENGAWASAN1. Pe",i%aa% a% (e%$aa&a%Pe%e$a'a% rauda!a"

Pe!a*&a%aa% Ja"i%a% Ke&e'ata% (aa Si&te" Ja"i%a% S#&

#!e' Me%teri

Ke(a!a Di%a& Ke&e'ata% Pr#-i%&ia% Ke(a!a Di%a& Ke&e'at

Ka,)(ate%?K#ta.

6/ D* , #e*0inn "n #en%


20/22

PERNA BPRS DA6AM PENCEGAFRAUD DI RS

MENGENA6I JENIS JENIS FRAUD

IKUT SERTA 6AKUKAN PENCEGAHAN TERJADINA

KERJASAMA DENGAN INSTANSI TERKAITDINASKESHATANORGANISASI PERUMAH SAKITANPRO

6AKUKAN INESTIGASI BI6A TERJADI FRAUDMONITORING DAN EA6UASI


21/22

PENUTUP 1

1. U(a+a (e%e$a'a% !e,i' ,ai* a$ar tia* (er%a' terai ti%a*a% Fra).

2. Per&ia(*a% Pe#"a% Pe%e$a'a% a% Be%t)* Ti" Pe%e$a' Fra) i RS

3. Me%$i*)ti TOT S#&ia!i&a&i a% Pe!ati'a% a%ti Fra) ,ai* i&e!e%$$ara*a%

#!e' IMRS PERSI "a)()% I%&tit)&i ter*ait !ai%%+a

4. Ti" Pe%e$a'a% Fra) ai, "e!a*)*a% ie%ti0*a&i aa! &e,e!)"

i&era'*a% *e(aa (e"eri*&aa% !a%)ta%

5. A(a,i!a (aa Pe"eri*&aa% !a%)ta% #!e' !e",a$a (e%$aa&a%

ite")*a% ,)*ti terai /ra) "a*a ti%a*a% re(re&i/ "e%ai t)$a&

(ara (e%e$a* ')*)".

7. BPRS IKUT SERTA DA6AM PEMBINAANPENCEGAHAN DAN INESTIGASI

BI6A TERJADI FRAUD

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22/22

B)*a% &e(erti e!a%$ +a%$ "e%ari "a%$&a

Jai*a%!a' BPRSP i%&tit)&i +a%$ t)!)& )%t)* "e%i%$*at*a")t) a% a*&e& (e!a+a%a%

R)"a' Sa*it i ti%$*at Pr#(i%&i.

TERIMA KASIH

bprs upaya pencegahan fraud lampung 06-8-2016

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