Sugiarti, Ida and Masturoh, Imas and Fadly, Fery (2022) Menelusuri Potensi Fraud dalam Jaminan Kesehatan Nasional melalui Rekam Medis di Rumah Sakit. Jurnal Kesehatan Vokasional, 7 (1). pp. 42-50. ISSN ISSN 2541‑0644 (print), ISSN 2599‑3275 (online)
![[img]](http://repo.poltekkestasikmalaya.ac.id/style/images/fileicons/text.png) |
Text
69056-248155-3-PB.pdf Download (686kB) |
Abstract
Background: The Health Social Security Administering Body has to pay more extensive claims due to fraud, resulting in state losses.One form of fraud found in the provider group is upcoding. Coding data and health records in medical records can be used as fraud detection. Objective: Tracing potential fraud by tracing the accuracy of diagnostic codes and clinical paths in medical records. Methods: A qualitative‑quantitative approach with a case study, a typhoid case. The research subjects were selected by purposive sampling. Quantitative research samples are medical records. The instrument used an observation sheet and interview guidelines. Data collection with; observation and in‑depth interviews. Quantitative data analysis is descriptive analysis and qualitative data is content analysis. Results: From 87 documents, the diagnosis code was 31.03% inaccurate. with a claim rate mismatch percentage of 26.44%. There are various causes of upcoding including the different coding rules between the diagnosis code based on ICD 10 and the code for claims purposes that refer to the regulations of the BPJS as outlined in the Minutes. 91.30% non‑conformity represents an increased claim rate. The most clinical pathway discrepancies were in the widal test items with a percentage of 21.84%. Conclusion: Upcoding is not always called fraud, there must be an element of intent to bring financial gain. Upcoding can change the claim to be higher. Clinical pathways are essential as a reference for health service actions.
| Item Type: | Article |
|---|---|
| Uncontrolled Keywords: | upcoding; clinical pathway; fraud; BPJS; ICD |
| Subjects: | K Law > K Law (General) K Law > KZ Law of Nations R Medicine > RA Public aspects of medicine |
| Divisions: | Jurusan RMIK > D3 Rekam Medis & Informasi Kesehatan |
| Depositing User: | Ida Sugiarti |
| Date Deposited: | 10 Oct 2024 01:00 |
| Last Modified: | 10 Oct 2024 07:36 |
| URI: | http://repo.poltekkestasikmalaya.ac.id/id/eprint/5310 |
Actions (login required)
 |
View Item |