scholarly journals Phenomenon of Causal Fraud Health Insurance in Hospitals: Theory of gear fraud

2021 ◽  
Vol 16 (4) ◽  
pp. 177-185
Author(s):  
Haruddin Haruddin ◽  
Dedi Purwana ◽  
Choirul Anwar
Keyword(s):  
Health Insurance ◽  
Health System ◽  
General Hospital ◽  
Leadership Style ◽  
Monitoring And Evaluation ◽  
External Factors ◽  
Insurance Fraud ◽  
National Guidelines ◽  
Financing System ◽  
Welfare Benefits

Objective: To describe and explore the experiences of hospital employees with the causes of fraud in the health insurance program at the hospitals. Design And Setting: This research was carried out at government hospitals in the Southeast Sulawesi Province in collaboration with BPJS Health, namely the Bahteramas Regional General Hospital and the Kendari City Regional General Hospital. Triangulation was carried out at BPJS Health, the Center for Health Insurance Financing at the Ministry of Health and the Center for Health Policy and Management at Gadjah Mada University, Yogyakarta. This research was conducted for one year, namely January 2020 to February 2021qualitative method with a phenomenological approach. Data collection methods were carried out through in-depth interviews, focus group discussions, and document studies. The number of participants in this study was 44 people consisting of doctors in charge of services, nurses, midwives, and case-mix team including coders who met the inclusion criteria. Data analysis used the Moustakas method. Result: The causes of health insurance fraud in hospitals financial motives (the desire to get money or material or economic or welfare benefits, get high service services and low employee salaries), behavioral motives (low integrity, lifestyle and employee habits of committing fraud0, and social motives (kinship, humanitarian factors, avoiding conflict, social position, and the existence of pressure), internal controls (a weak monitoring system, poorly enforced regulations, unclear regulations and limited hospitals providing services, no monitoring and evaluation, and there are no sanctions for fraud perpetrators), revenue targets (hospitals income and increasing the number of claims), leadership (leadership style or weak leadership in the hospitals and the absence of transparency), incentive systems (poor distribution of incentives and the absence of transparency of services from hospitals management), National Health Insurance (NHI) regulations (dynamic regulations and the availability of the National Guidelines for Medical Services has not been fulfilled and there is no standard for readmission and fragmentation), the NHI financing system (inconvenience of the financing system and the adequacy of the INA-CBGs tariff calculation), and the BPJS Health system (inconvenience of the BPJS Health system and the BPJS Health system which makes it difficult). Conclusions: The causes of health insurance fraud in hospitals can be explained by the gear fraud theory that Internal factors are the main cause and external factors predispose to health insurance fraud in hospitals. These internal and external factors interact with each other like the working mechanism of a gear. Understanding the theory of gear fraud will help formulate fraud prevention efforts in health insurance programs in hospitals that are more comprehensive and focus on eliminating the causes of fraud.

scholarly journals Pengaruh Kepemimpinan Demokratis Kepala Ruang Rawat Inap Terhadap Kepuasan Kerja Perawat di Rumah Sakit Umum Aro Pekalongan

2019 ◽  
Vol 7 (2) ◽  
pp. 109-114
Author(s):  
Broto Rahardjo ◽  
Chriswardani Suryawati ◽  
Farid Agushybana
Keyword(s):  
Job Satisfaction ◽  
General Hospital ◽  
Leadership Style ◽  
Monitoring And Evaluation ◽  
Employee Motivation ◽  
Research Subjects ◽  
Cross Sectional ◽  
Democratic Leadership ◽  
Nurse Job Satisfaction ◽  
Periodic Monitoring

Leadership styles that are less suitable can reduce employee motivation, performance and job satisfaction. 4 out of 10 nurses in the inpatient room of Aro Pekalongan General Hospital felt dissatisfied with the leadership of the head of the inpatient room. Therefore a study was conducted to analyze the influence of the democratic leadership style of the inpatient head on the job satisfaction of nurses in Aro Pekalongan General Hospital.The study design was cross sectional with an observational quantitative approach. The research subjects were 32 nurses in the inpatient room of Aro General Hospital who were selected by the total sampling method. Data was collected by questionnaire. Processing and analysis of data using multiple logistic regression analysis.The results showed the variables of democratic leadership style related to nurse job satisfaction in Aro Pekalongan Hospital were delegation of responsibility variables (p = 0.005) and headroom decision-making variables (p = 0.034), while other variables not related to nurse job satisfaction were variable of headroom activity (p = 0.077) and empathy variable (p = 0.075). The variable delegation of tagging answers to the head of the room has a 19 times better effect on influencing nurse job satisfaction compared to the head of the room with poor delegation of responsibilities (p = 0.011 Exp (B) = 19.826).       It is recommended for management for periodic monitoring and evaluation, the selection of the head of the room is based on the length of work, competence and experience of advice for the head of the room to improve effective communication and hold regular meetings with nurses in the inpatient room of Aro Pekalongan General Hospital.

Prävention – Lohnt sich Prävention für die gesetzlichen - Krankenkassen in Deutschland?

2020 ◽  
Vol 25 (03) ◽  
pp. 128-129
Keyword(s):  
Health Insurance ◽  
Disease Prevention ◽  
Economic Impact ◽  
Statutory Health Insurance ◽  
Insurance Fund ◽  
Chronische Erkrankungen ◽  
Health Insurance Fund ◽  
Health Econ ◽  
Financing System ◽  
Statutory Health Insurance Fund

Weinhold et al. Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany? Eur J Health Econ 2019; 20 (8): 1181–1193 Das deutsche Gesundheitssystem wird durch vermeidbare chronische Erkrankungen in besonderem Maße belastet. Die Finanzierung geeigneter Präventionsmaßnahmen obliegt den Krankenkassen. Weinhold et al. untersuchten in einer retrospektiven Studie die ökonomischen Auswirkungen von Prävention für die GKV.

The evaluation of trustworthiness to identify health insurance fraud in dentistry

2017 ◽  
Vol 75 ◽  
pp. 40-50 ◽  
Author(s):  
Shu-Li Wang ◽  
Hao-Ting Pai ◽  
Mei-Fang Wu ◽  
Fan Wu ◽  
Chen-Lin Li
Keyword(s):  
Health Insurance ◽  
Insurance Fraud

WHICH HEALTH FINANCING MODEL IS BETTER: TAX-FINANCED OR SOCIAL HEALTH INSURANCE? WHAT DOES INTERNATIONAL EXPERIENCE PROVE?

2021 ◽  
Vol 67 (1) ◽  
pp. 9-9
Author(s):  
E.G. Potapchik ◽  
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Structural Characteristics ◽  
Health Expenditures ◽  
Health Financing ◽  
Health Care Expenditures ◽  
Developed Countries ◽  
Financing System ◽  
Financing Model ◽  
The Developed Countries

In Russia disputes on the need to abandon Compulsory Health Insurance (CHI) and return to the tax-based financing are yet to subside. At present, after the statement of the President of the Russian Federation V. Putin about the possibility to establish a state health care corporation, discussions on the issue have only escalated. Purpose. To conduct a comparative assessment of the public health financing model impact on the access and structural characteristics of health care delivery in the developed countries. Material and methods. Assessment of the potential impact of public funding models on the health system performance is carried out by analyzing variations in the main indicators of financial access, health care uptake and health status of the population, achieved in the developed countries with different health financing models. Results. Health care expenditures in countries with CHI are higher than in countries with the tax-based financing model. In countries with CHI the share of administrative expenses is slightly higher than in countries with the tax-based financing system. The share of spending on preventive care is slightly higher in countries with the tax-based financing system. There is a slightly lower level of outpatient and inpatient care uptake in countries with the tax-based financing system compared to countries with CHI. The premature mortality rate in countries with CHI is slightly lower than in countries with the tax-based system. Conclusion. The obtained data indicate that there are no significant differences in the access and structural characteristics of medical care in the health care system of the developed countries with different financing models. The main difference remains the level of health expenditures. In countries with CHI, the level of health expenditures is higher than in countries with the tax-based financing, which is largely due to the existence of a separate source of funding. The level of administrative costs in countries with CHI is also higher than in countries with the tax-based system.

The regulation of health care in Scandinavia: professionals, the public interest and trust

2018 ◽  
pp. 61-76
Author(s):  
Karsten Vrangbæk
Keyword(s):  
Health Care ◽  
Public Policy ◽  
Health Insurance ◽  
Health System ◽  
Health Systems ◽  
Public Interest ◽  
State Level ◽  
Professional Regulation ◽  
The Public ◽  
Voluntary Health Insurance

Scandinavian health systems have traditionally been portrayed as relatively similar examples of decentralised, public integrated health systems. However, recent decades have seen significant public policy developments in the region that should lead us to modify our understanding. Several dimensions are important for understanding such developments. First, several of the countries have undergone structural reforms creating larger governance units and strengthening the state level capacity to regulate professionals and steer developments at the regional and municipal levels. Secondly, the three Nordic countries studied experienced an increase in the purchase of voluntary health insurance and the use of private providers. This introduces several issues for the equality of users and the efficiency of the system. This paper will investigate such trends and address the question: Is the Nordic health system model changing, and what are the consequences for trust, professional regulation and the public interest?

Consolidating the social health insurance schemes in China: towards an equitable and efficient health system

The Lancet ◽  
2015 ◽  
Vol 386 (10002) ◽  
pp. 1484-1492 ◽  
Author(s):  
Qingyue Meng ◽  
Hai Fang ◽  
Xiaoyun Liu ◽  
Beibei Yuan ◽  
Jin Xu
Keyword(s):  
Health Insurance ◽  
Health System ◽  
Social Health Insurance ◽  
Social Health ◽  
The Social

Drivers of potentially avoidable emergency admissions in Ireland: an ecological analysis

2018 ◽  
Vol 28 (6) ◽  
pp. 438-448 ◽  
Author(s):  
Brenda Lynch ◽  
Anthony P Fitzgerald ◽  
Paul Corcoran ◽  
Claire Buckley ◽  
Orla Healy ◽  
...  
Keyword(s):  
Health Insurance ◽  
Health System ◽  
Private Health Insurance ◽  
Insurance Coverage ◽  
Emergency Admission ◽  
Health Insurance Coverage ◽  
County Level ◽  
Emergency Admissions ◽  
Admission Rates ◽  
System Factors

BackgroundMany emergency admissions are deemed to be potentially avoidable in a well-performing health system.ObjectiveTo measure the impact of population and health system factors on county-level variation in potentially avoidable emergency admissions in Ireland over the period 2014–2016.MethodsAdmissions data were used to calculate 2014–2016 age-adjusted emergency admission rates for selected conditions by county of residence. Negative binomial regression was used to identify which a priori factors were significantly associated with emergency admissions for these conditions and whether these factors were also associated with total/other emergency admissions. Standardised incidence rate ratios (IRRs) associated with a 1 SD change in risk factors were reported.ResultsNationally, potentially avoidable emergency admissions for the period 2014–2016 (266 395) accounted for 22% of all emergency admissions. Of the population factors, a 1 SD change in the county-level unemployment rate was associated with a 24% higher rate of potentially avoidable emergency admissions (IRR: 1.24; 95% CI 1.04 to 1.41). Significant health system factors included emergency admissions with length of stay equal to 1 day (IRR: 1.20; 95% CI 1.11 to 1.30) and private health insurance coverage (IRR: 0.92; 95% CI 0.89 to 0.96). The full model accounted for 50% of unexplained variation in potentially avoidable emergency admissions in each county. Similar results were found across total/other emergency admissions.ConclusionThe results suggest potentially avoidable emergency admissions and total/other emergency admissions are primarily driven by socioeconomic conditions, hospital admission policy and private health insurance coverage. The distinction between potentially avoidable and all other emergency admissions may not be as useful as previously believed when attempting to identify the causes of regional variation in emergency admission rates.

scholarly journals Health Insurance in Myanmar: The Views and Perception of Healthcare Consumers and Health System Informants on the Establishment of a Nationwide Health Insurance System

Risks ◽  
2018 ◽  
Vol 6 (3) ◽  
pp. 81
Author(s):  
Marjolein van Rooijen ◽  
Chaw-Yin Myint ◽  
Milena Pavlova ◽  
Wim Groot
Keyword(s):  
Health Insurance ◽  
Health System ◽  
Rural Areas ◽  
Social Protection ◽  
Vulnerable Groups ◽  
Health Insurance System ◽  
Structured Interviews ◽  
Insurance System ◽  
Supplementary Health Insurance ◽  
Insurance Model

(1) Background: Health insurance and social protection in Myanmar are negligible, which leaves many citizens at risk of financial hardship in case of a serious illness. The aim of this study is to explore the views of healthcare consumers and compare them to the views of key informants on the design and implementation of a nationwide health insurance system in Myanmar. (2) Method: Data were collected through nine focus group discussions with healthcare consumers and six semi-structured interviews with key health system informants. (3) Results: The consumers supported a mandatory basic health insurance and voluntary supplementary health insurance. Tax-based funding was suggested as an option that can help to enhance healthcare utilization among the poor and vulnerable groups. However, a fully tax-based funding was perceived to have limited chances of success given the low level of government resources available. Community-based insurance, where community members pool money in a healthcare fund, was seen as more appropriate for the rural areas. (4) Conclusion: This study suggests a healthcare financing mechanism based on a mixed insurance model for the creation of nationwide health insurance. Further inquiry into the feasibility of the vital aspects of the nationwide health insurance is needed.

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