1. Pencegahan KPK Sektor
Kesehatan
The Interagency Cooperation on
Handling Fraud in Indonesia
National Healthcare Program
Pahala Nainggolan
Deputy of Prevention and Monitoring
Corruption Eradication Commission (KPK), Indonesia
Magelang, 8 December 2022
2. Challenges of Healthcare Fraud
Fraud
Information asymmetry and an absence of effective
counter-fraud measures are the drivers of fraud in
healthcare program in Indonesia
Awareness
Gap of knowledge and understanding between patient,
medical personnel, health facility, the supervisory and
law enforcement apparatus
Oversee
No one responsible to oversee fraud in health facilities.
Regulation does not decide who has a mandate to
conduct medical audit.
The competence of fraud detection in health service is
undeveloped
3. 000
KPK Interagency Cooperation on Fraud
Handling
Clinical Pathway
Periodical review
of tarif
Improving data
accuracy
Strengthening the
oversee unit
Healthcare System
Promoting
Performance-
based Capitation
Optimizing
capitation
Capitation
Management
E-catalog for
purchasing
Improving in the
national drugs
requirement plan
Drug Management
Establish a task
force team
Initiate law
enforcement for
perpetrators in JKN
Fraud Handling
Improving e-
catalogue features
and guideline
Promoting e-
payment
Medical Device
Formulation of
implementable and
effective
recommendation
Intensive Coordination
and Engagement with
Related Agencies since
planning and
budgeting
Strengthening the
channel for whistle
blower, irregularities, and
corrupt practices
4. 2016
• International
Supervision Best
Practice on
National
Healthcare Study
in the US
2017
• Establishment of
task force
• Designing
guidelines of
fraud prevention
system, fraud
detection, and
fraud resolution
2018
• Piloting of law
enforcement for
medical fraud in
social healthcare
program
• Apply sanctions
(remedy
program,
administrative,
civil code or
criminal code)
GOALS
• Formulating step-by-step actions to develop
oversee system and fraud handling
mechanism in social healthcare program
• Preventing state-loss in social healthcare
program
Task Force of Fraud Handling in JKN
2019
Finalize the Health
Minister Decree on
National Health
Insurance Fraud
Prevention and Handling
5. 01
Cataract
Surgery
02
Physiotheraphy
03
Hospital Type
Classification
• Unnecessary treatment on
Cataract surgery
• Fragmentation on patient
treatment’s billing
• Cancelled service
• The absent of clinical pathway
• Fragmentation and Unbundling
Phantom billing
• Unnecessary treatment
• The absent of clinical pathway
• 68% hospitals are unqualified
for existing hospital class/type
Piloting: Joint-Operation on JKN Fraud Handling
3 provinces
9 Hospitals
on-site
inspection
24 team
members
6. • Designing guidelines of fraud prevention for all JKN related party
Task Force of Fraud Handling in JKN
Prevention Workgroup
BPJS, Ministry of Health (Inspectorate and DG of Health Service), KPK (Deputy of
Prevention)
Resolution Workgroup
BPJS, KPK (Complaint Handling Directorate), Government Internal Auditors (BPKP) +
Association of Medical Doctors + Regional Health Authority
• Designing guidelines of fraud detection, including data
exchange procedure, analysis and follow-up mechanism
• Piloting of law enforcement based on data analysis of
claims that allegedly fraud
Detection Workgroup
• Designing guidelines of fraud resolution including level of fraud, resolution
procedures, and sanctions to be applied
BPJS, KPK (Complaint Handling Directorate), Government
Internal Auditors (BPKP)
7. Fraud Identification
Information Gathering
Fraud is not
detected
Remedy
Administration/
Ethics
Fraud is detected
Report to Law
Enforcement
• Punishment is the
instrument of the last
resort
• Principle of ultimum
remidium
reminder
Detection Guideline
Prevention Guideline
Resolution Guideline
Health Minister Decree on Fraud Prevention and
Handling in JKN
