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Kata kunci : kecurangan, segitiga kecurangan, kebijakan pencegahan fraud,jaminan kesehatan nasional
The National Health Insurance (JKN) held by the Social Security Agency (BPJS)Health has started to be implemented from 1 Indonesia's Health InsuranceProgram in January 2014. The implementation of a national insurance programfound the risk. The risk of occurrence of fraud (fraud) in Indonesia is very highbut it is still difficult to identify fraud risk events. This is supported by the lack ofawareness of all parties, both from patients, providers and insurance companiesalthough such actions are felt presence. Health fraud is a serious threat to theentire world, which led to financial abuse of scarce resources and the negativeimpact on access to health care, infrastructure, and social determinants of health.Health fraud associated with increased health care costs in the United States. Thisstudy was to analyze the influence of the dimensions of the fraud triangle in fraudprevention policies towards the National Health Insurance program which is thereason for health fraud. This study used a qualitative approach. Data collectiontechniques such as interview guides, recorders, written records and documents.The results of a study reported stress analysis, opportunity, and rationalization ofthe risk of fraud incident and presents examples of how policy has an impact onthe National Hospital Dr. Cipto Mangunkusumo. This thesis will then provideadvice on how to prevent future fraudulent health to reduce health spending anduse of resources for the benefit of the National Hospital Dr. CiptoMangunkusumo.
Keywords : Fraud, fraud triangle, fraud prevention policies, national healthinsurance
ABSTRAK RSUP Fatmawati sebagai salah satu rumah sakit pengampu PTRM di wilayah DKI Jakarta melakukan pembinaan terhadap beberapa satelit di wilayah kerjanya. Cakupan satelit yang rendah, masalah penggunaan napza lain serta beberapa satelit yang merasakan adanya perbedaan cara petugas pembina melaksanakan bimbingan membuat peneliti merasa perlu untuk melakukan evaluasi terhadap pembinaan dan efektivitasnya terhadap layanan PTRM di satelit. Penelitian ini dilakukan di RSUP Fatmawati dan 4 satelit diwilayah DKI Jakarta. Metode deskriptif-kualitatif digunakan untuk mengetahui evaluasi pembinaan PTRM RSUP Fatmawati di satelit dan; efektivitas pembinaan terhadap kualitas layanan di 4 satelit wilayah DKI Jakarta. Data diperoleh dari hasil wawancara mendalam dengan informan secara purposive yaitu petugas PTRM RSUP Fatmawati, petugas dan klien di satelit serta didukung dengan FGD dan studi dokumen laporan terkait. Selanjutnya data yang diperoleh direduksi, dikelompokkan sesuai pokok permasalahan, dan dianalisis dengan membandingkan antara hasil wawancara dan dokumen dalam bentuk uraian. Hasil penelitian ini menunjukkan, pertama, evaluasi pembinaan PTRM RSUP Fatmawati di satelit menunjukkan: (1) belum tersedia SPO pelaksanaan supervisi ke satelit; (2) belum seragamnya materi pelaksanaan supervisi oleh petugas; (3) persepsi petugas pelaksana mengenai layanan belum kearah kualitas pelayanan di satelit; (4) belum ada pengawasan dari Kementerian Kesehatan terkait pelaksanaan supervisi petugas RS Pengampu. Untuk itu diperlukan upaya untuk mengatasinya dengan membuat SPO pelaksanaan supervisi ke satelit yang baku dan dapat diterapkan dalam pelaksanaan supervisi ke satelit. Kedua, pembinaan sudah dilaksanakan secara efektif terhadap aspek output. Dikatakan efektif yaitu apabila tujuan yang ingin dicapai telah terlaksana, hal ini dibuktikan dengan keberhasilan layanan PTRM di 4 satelit wilayah DKI Jakarta. Pembinaan belum efektif terhadap aspek input dan proses layanan PTRM di satelit. Upaya yang harus dilakukan petugas Pembina adalah membuat usulan kepada Kementerian Kesehatan agar sistem pembinaan yang dilakukan oleh RS pengampu agar dapat mempunyai kewenangan terhadap pelayanan di satelit atau melakukan koordinasi kepada stake holder terkait masalah terhadap SDM dan fasilitas di satelit.
ABSTRACT Fatmawati Hospital is a referral hospital of MMT in Jakarta supervision to multiple satellites in the working area. Satellite coverage is low, other drug use problems, and some satellite that feel the difference in the way the coaches implement guidance makes researchers feel the need to evaluate the effectiveness of the guidance and the MMT in satellite services. The research was conducted in Fatmawati and 4 satellite region of Jakarta. Descriptive-qualitative method used to determine the evaluation of coaching MMT Fatmawati in satellite and; effectiveness of supervision on the quality of satellite services in 4 areas of Jakarta. Data obtained from in-depth interviews with informants purposively namely Fatmawati MMT officers, officials and clients in the satellite and supported by focus group study of documents and related reports. Furthermore, the data obtained is reduced, grouped according to subject matter, and analyzed by comparing the results of interviews and documents in narrative form. The results showed, first, formation evaluation MMT Fatmawati in satellite shows: (1) has not been available to the Satellite SPO implementation supervision, (2) the material has not been uniform implementation of supervision by officers, (3) perceptions regarding the executive officers yet toward service quality of service on satellites, (4) there is no supervision of the Ministry of Health on the implementation of the supervision officer RS custodian. Therefore, efforts to cope with the implementation of supervision to make SPO satellite and can be applied in the implementation of supervision to the satellite. Second, coaching is carried out effectively against the output aspect. Is said to be effective if the objectives have been accomplished, this is evidenced by the success of MMT services in 4 satellite Jakarta area. Yet effective coaching input and process aspects of MMT in the satellite services. Efforts must be made officers of PTRM Fatmawati Hospital is to make a proposal to the Ministry of Health for the system development undertaken by RS custodian in order to have the authority to services at the satellite or to coordinate the relevant stakeholders on HR issues and in satellite facilities.