Studi Kualitatif Fraud Pelayanan Kesehatan : Literature Review
Qualitative Study of Health Service Fraud : Literature Review
Abstract
Latar Belakang: Potensi terjadinya fraud, baik yang terjadi di rumah sakit, staf medis maupun rekam medis perlu dimasukkan sebagai bagian dari suatu sistem yang dapat mencegah terjadinya sebagai mekanisme anti fraud untuk meminimalkan kerugian pasien dan rumah sakit secara keseluruhan.
Tujuan: Artikel ini bertujuan untuk mengidentifikasi penelitian kualitatif terkait fraud pelayanan kesehatan.
Metode: review artikel dilakukan dengan menggunakan tiga database bibliografi. Artikel diseleksi berdasarkan publikasi 10 tahun terakhir. Ektsraksi data dilakukan dengan menggunakan Prisma flowchart (gambar1), dan artikel yang diinklusi terlebih dilakukan pengecekan kelayakan studi menggunakan instrument Strobe.
Hasil: Sebanyak 12037 diperoleh dari tiga database. 20 artikel sesuai dengan kriteria inklusi dan 8 artikel yang dipilih dalam tinjauan literatur ini. Berdasarkan hasil literatur review ditemukan bahwa fraud di pelayanan kesehatan telah dilakukan di beberapa negara maju dan berkembang, fraud rentan ditemukan diantara klaim asuransi kesehatan dan perawatan di rumah sakit. Potensi kecurangan di rumah sakit disebabkan oleh sosial budaya yang menganut budaya konsumerisme dan materialisme, serta motif dari pelaku sehingga menghalalkan segala cara untuk mencapai tujuan dan anggapan pembenaran.
Kesimpulan: Fraud pada pelayanan kesehatan di rumah sakit, praktik-praktik kecurangan dan penyalahgunaan perawatan kesehatan telah menjadi pusat perhatian dan masalah utama di dunia kesehatan dari tahun ke tahun, dimana fraud terjadi dalam keadaan dan situasi yang berhubungan dengan proses layanan, cakupan atau manfaat pelayanan yang berdampak pada menabungnya pembiayaan layanan kesehatan. Fraud menjadi ancaman utama bagi ekonomi di seluruh dunia.
References
Albrecht, W. S. et al. (2018) Fraud examination. Cengage Learning.
Arens A. Alvin, Ellder J. Ronal & Beasley Mark s. 2017. Auditing dan Jasa assurance Pendekatan Terintegrasi. Jakarta:Erlangga.
Ardini, L., Maryam, D. and Munaa, N. (2020) ‘Fraud Detection in Indonesia National Health Insurance Implementation: a Phenomenology Experience From Hospital’, 1st International Conference of Business and Social Sciences, 1(1), pp. 263–270. Available at: http://icobuss-stiesia.ac.id/prod/index.php/icobuss1st/article/view/26.
Arshad, R., Ainul, W., Wan, A., Razali, M., & Bakar, N. A. (2015). Catch the “ Warning Signals â€: The Fight against Fraud and Abuse in Non-Profit Organisations. Procedia Economics and Finance, 28(April), 114–120. https://doi.org/10.1016/S2212-5671(15)01089-8
Anggraeni, et al. (2019). PERKEMBANGAN PROGRAM JKN TAHUN 2019.
Copeland, L. et al. (2012) ‘Applying business intelligence concepts to Medicaid claim fraud detection’, Journal of Information Systems Applied Research, 5(1), p. 51.
Cortesão, L. (2005) ‘Fraud management systems in telecommunications: a practical approach’, Proceeding of ICT.
Bauder, R., Khoshgoftaar, T. M., & Seliya, N. (2017). A survey on the state of healthcare upcoding fraud analysis and detection. Health Services and Outcomes Research Methodology, 17(1), 31–55. https://doi.org/10.1007/s10742-016-0154-8
Busch, Rebecca S. (2008). Healthcare Fraud Auditing and Detection Guide. In HEALTHCARE FRAUD : AUDITING & DETECTION GUIDE.
Fathurrohman, N. and Dewi, A. (2018) ‘Potential Fraud in The Primary Healthcare’, Jurnal Medicoeticolegal dan Manajemen Rumah Sakit, 7(3). doi: 10.18196/jmmr.7373.
Goldmann, P. (2009). Anti-Fraud Risk and Control Workbook. Journal of Chemical Information and Modeling, 53(9). https://doi.org/10.1017/CBO9781107415324.004
Gee, J., & Button, M. (2015). The financial cost of healthcare fraud 2015 What data from around the world shows How UK FTSE listed companies can reduce the cost of fraud and maximise profitability. January 2015.
Gee, J., Button, M., & Brooks, G. (2016). The financial cost of Healthcare fraud. Servamus Community-Based Safety and Security Magazine, 28–31.
Grove, H. and Clouse, M. (2020) ‘Journal of Forensic and Investigative Accounting Volume 12 : Issue 3 , Special Issue 2020 Journal of Forensic and Investigative Accounting Volume 12 : Issue 3 , Special Issue 2020’, 12(3), pp. 422–441.
Hartati, T. S. (2016) ‘Pencegahan Kecurangan (Fraud) dalam Pelaksanaan Program Jaminan Kesehatan pada Sistem Jaminan Sosial Kesehatan (Sjsn)(Studi di Rumah Sakit Umum Daerah Menggala Tulang Bawang)’, Fiat Justisia: Jurnal Ilmu Hukum, 10(4), pp. 715–732.
Holmberg, S., & Rothstein, B. (2011). Quality of Government and Access to Safe Water. QoG Working Paper Series, March 2011, 1–16.
Kalb P.E. (1999). Health care fraud and abuse laws. American Medical Association. JAMA, 282(12), 1163–1169. https://doi.org/10.5858/2006-130-1169-hcfaal
Kirlidog, M., & Asuk, C. (2012). A Fraud Detection Approach with Data Mining in Health Insurance. Procedia - Social and Behavioral Sciences, 62, 989–994. https://doi.org/10.1016/j.sbspro.2012.09.168
Khoiri, A., & et al. (2020). Potential of Hospital Fraud in the Indonesia National Health Insurance Era (A Descriptive Phenomenological Research). Indian Journal of Forensic Medicine & Toxicology, 14(3), p1132–p1136.
Khoiri, A., Hidayat, W., Chalidyanto, D., & Suhariadi, F. (2020). Disposition of Policy Implementers: Study on The Hospitals Payment System Change in The Indonesian National Health Insurance Era. Indian Journal of Forensic Medicine & Toxicology, 14(4).
Legotlo, T. G., Hons, B., Mutezo, A., & Hons, B. (2018). Understanding the types of fraud in claims to South African medical schemes. South African Medical Journal, 108(4), 299–303. https://doi.org/10.7196/SAMJ.2018.v108i4.12758
Legotlo, T. G., & Mutezo, A. (2018). Understanding the types of fraud in claims to South African medical schemes. South African Medical Journal, 108(4), 299–303. https://doi.org/10.7196/SAMJ.2018.v108i4.12758
Lorensa, C. N., Fallah, S., & Sanggenafa, M. . (2018). Pengaruh Budaya Organisasi Dan Peran Auditor Internal Terhadap Pencegahan Fraud. Jurnal Akuntansi Fakultas Ekonomi Dan Bisnis Universitas Negeri Padang, 13(November), 1–15.
MacKey, T. K., & Liang, B. A. (2012). Combating healthcare corruption and fraud with improved global health governance. BMC International Health and Human Rights, 12(1). https://doi.org/10.1186/1472-698X-12-23
Mansor, N., Nuhu, M. S., Sultan, U., & Abidin, Z. (2015). Fraud Triangle Theory and Fraud Diamond Theory : Understanding the Convergent and Divergent for Future. 7(28), 30–37. https://doi.org/10.6007/IJARAFMS/v5-i4/1823
Maidin, & Palutturi. (2016). The study of Implementation of National Health Insurance Cross Province South Sulawesi, South East Sulawesi https://core.ac.uk/download/pdf/295415842.pdf
Nawawi, A., & Salin, A. S. A. P. (2018). Internal Control and Employees’ Occupational Fraud on Expenditure Claims. Journal of Financial Crime, 25(3), 891–906. https://doi.org/https://doi.org/10.1108/JFC-07-2017-0067
Palutturi, S., Makkurade, S. R., Ahri, R. A., & Putri, A. S. E. (2019). Potential for fraud of health service claims to BPJS Health at Tenriawaru Public Hospital, Bone Regency, Indonesia. International Journal of Innovation, Creativity and Change, 8(5), 70–90.
Permenkes RI No.16 Tahun 2019 Tentang Pencegahan Dan Penanganan Kecurangan (Fraud) Serta Pengenaan Sanksi Administrasi Terhadap Kecurangan (Fraud) Dalam Pelaksanaan Program Jaminan Kesehatan, (2019).
Rosyida, I. A. (2018) ‘Implementasi Pengendalian Internal Pada’, Ekonomi Universitas Kediri, 3(1), pp. 47–63.
Santoso, B., Hendrartini, J., Djoko Rianto, B. U., & Trisnantoro, L. (2018). System for Detection of National Healthcare Insurance Fraud Based on Computer Application. Public Health of Indonesia, 4(2), 46–56. https://doi.org/10.36685/phi.v4i2.199
Sowah, R. A., Kuuboore, M., Ofoli, A., Kwofie, S., Asiedu, L., Koumadi, K. M., & Apeadu, K. O. (2019). Decision Support System (DSS) for Fraud Detection in Health Insurance Claims Using Genetic Support Vector Machines (GSVMs). Journal of Engineering (United Kingdom), 2019(January 2007). https://doi.org/10.1155/2019/1432597
Taqi, M., & Ismail, T. (2020). Antecedent Variables and Consequences of Religiosity on Fraud. International Journal of Financial Research, 11(1), 43–48. https://doi.org/10.5430/ijfr.v11n1p43
Thornton, D., Brinkhuis, M., Amrit, C., & Aly, R. (2015). Categorizing and Describing the Types of Fraud in Healthcare. Procedia Computer Science, 64, 713–720. https://doi.org/10.1016/j.procs.2015.08.594
Trisnantoro, L. (2014). Pengantar Kegiatan.
Trisnantoro, L. (2015). Peran BPJS kesehatan dalam pencegahan fraud dan abuse dalam Sistem Jaminan Kesehatan nasional (JKN).
Utami, I., Astiti, Y. W., & Mohamed, N. (2019). Fraud intention and machiavellianism: An experimental study of fraud triangle. International Journal of Financial Research, 10(5), 269–279. https://doi.org/10.5430/ijfr.v10n5p269
Zuberi, O., & Mzenzi, S. I. (2019). Analysis of employee and management fraud in Tanzania Omari. Journal of Financial Crime, 26(2), 412–431. https://doi.org/10.1108/JFC-01-2018-0012
Authors who publish with Journal of Public Health and Pharmacy retain the copyright of their work. The journal applies a Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0), which grants the following rights:
-
Copyright Retention: Authors retain the copyright of their work, maintaining full control over their intellectual property without restrictions.
-
Right of First Publication: Authors grant the journal the right of first publication of their work. This ensures that the work is initially published and credited in Journal of Public Health and Pharmacy.
-
License to Share and Reuse: The work is licensed under CC BY-SA 4.0, allowing others to copy, distribute, remix, and build upon the work for any purpose, even commercially, as long as proper credit is given to the authors, and any new creations are licensed under the same terms.
