Development, including health insurance in developing countries shows that public awareness has increased and realized that the main solution to health services is through health insurance. But at the same time all parties are also trying to benefit as much as possible in the process.
Fraud (Fraud Auditing) in health care as a form called a deliberate effort made to create a benefit that should not be enjoyed either by individuals or institutions and can harm others.
Fraud (fraud auditing) in the health service conducted on hal2 or circumstances and situations associated with the process of health care, coverage or benefits of health services and financing.
In the health service is also known referred to as other forms of abuse that can harm the health service. However, this term is more widely used in health insurance is defined as activities or actions that harm the health service but not included in the category of fraud (fraud auditing). Abuse can be malpractice or overutilization.
Based on the Heath Insurance Assosiciation of America (HIAA), fraud in health care or health insurance can be categorized as follows:
- Fraud by the participants as a consumer health insurance
- Fraud by health providers (providers)
- Fraud by the insurance company
Thus, the fraud (fraud auditing) can be done by the parties relating to the health services that need to be traced from any party who has made fraud (fraud auditing) it.
Fraud (fraud auditing) are usually done by consumers or health insurance participants include:
- Making untrue statements in the filing of the claim
- Making untrue statements in terms of eligibility to obtain health services or at the time of claim.
Fraud by the Giver of Health Services (providers) can be done either by individuals in these institutions such as doctors, nurses, etc., as well as the institution that intentionally doing fraud. Form of fraud (fraud auditing) by the individual intentionally done to increase the incentives for the concerned.
Form of fraud (fraud auditing) are usually done by the Giver of Health Services, among others:
- Filing of claims with credit service or action that is not given, such as laboratory tests conducted on 2 types of tests, but presented as 3 types of tests or more.
- Manipulation of the diagnosis by raising the level of action such as appendiectomy charged appendiectomy with complications that require major surgery, so charging a higher tariff.
- Falsifying the date and duration of treatment days. This usually happens by adding the number of patient days by adding the date when the patient’s treatment was to come home.
- Claims by charging a greater rate than they should, for example, medical equipment bills larger than the regular price.
- Claim with the trade name drug when given a drug with a generic name.
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