Good Practices in Social Security Good Practices in Social Security

The identification and sharing of good practices helps social security organizations and institutions to improve their operational and administrative efficiency.

In the context of the ISSA, a good practice is defined as any type of experience (e.g. an action, a measure, a process, a programme, a project, or a technology) implemented within a social security organization that fosters the improvement of its administrative and operational capacities, and/or the efficient and effective delivery of programmes. The good practices selected by the ISSA focus on topics related to the priorities as defined in the programme and budget of the Association. The good practices are from member institutions of the ISSA and are primarily collected through the work of the  ISSA Technical Commissions and the ISSA Good Practice Awards.

Years
Themes
Region
Country
 
Back

DEFRADA (Deteksi Potensi Fraud Dengan Analista Data Klaim): The development of a fraud detection tool in hospital services

DEFRADA (Deteksi Potensi Fraud Dengan Analista Data Klaim): The development of a fraud detection tool in hospital services

Social Security Administering Body for the Health Sector | Indonesia
DEFRADA (Deteksi Potensi Fraud Dengan Analista Data Klaim): The development of a fraud detection tool in hospital services

Fraud incidence in healthcare is not easy to find. As a country that started its National Health Insurance program (Jaminan Kesehatan Nasional – JKN) in 2014, there are not many parties that provide fraud detection tools for the Indonesia-Case Based Group (INA-CBG) case-mix system. In addition, the law that establishes an investigation for potentially fraudulent incidents is still being drafted. On the other hand, there is a significant increase in the number of JKN participants and in the number of claims. By the end of 2017, the number of claims submissions was 80,641,271. The situation encouraged the Social Security Administering Body for the Health Sector (BPJS Kesehatan) to develop DEFRADA, a fraud detection tool for INA-CBG claims of referral health services.

This paper outlines the implementation of DEFRADA and its achievements in cost efficiency for the JKN. In 2017, DEFRADA contributed about 25 to 30 per cent of the total gains in cost efficiency. The implementation shows efficiency in data analysis offers room for improvement in the future.

Implementation year2019
Topics: Governance, Information and communication technology
PDF:
EN
|
FR
|
ES
|

Upcoming events Upcoming events