Social Security Administering Body for the Health Sector
Indonesia
Asia and Pacific

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

Implementation year
2017

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.

Topic:
Error, evasion and fraud
Guideline