STUDI FENOMENOLOGI FRAUD PROGRAM JAMINAN KESEHATAN PADA SUMBER DAYA MANUSIA DI RUMAH SAKIT

HARUDDIN, . (2022) STUDI FENOMENOLOGI FRAUD PROGRAM JAMINAN KESEHATAN PADA SUMBER DAYA MANUSIA DI RUMAH SAKIT. Doktor thesis, UNIVERSITAS NEGERI JAKARTA.

	Text COVER.pdf Download (1MB)
	Text BAB 1.pdf Download (322kB)
	Text BAB 2.pdf Restricted to Registered users only Download (491kB) | Request a copy
	Text BAB 3.pdf Restricted to Registered users only Download (340kB) | Request a copy
	Text BAB 4.pdf Restricted to Registered users only Download (1MB) | Request a copy
	Text BAB 5.pdf Restricted to Registered users only Download (158kB) | Request a copy
	Text DAFTAR PUSTAKA.pdf Download (319kB)
	Text LAMPIRAN.pdf Restricted to Registered users only Download (321kB) | Request a copy

Abstract

Tujuan penelitian adalah menemukan esensi dari pengalaman SDM di rumah sakit terhadap fraud dalam program jaminan kesehatan. Desain penelitian ini menggunakan metode kualitatif dengan pendekatan fenomenologi. Metode pengumpulan data dilakukan melalui wawancara, focus group discussion (FGD) dan studi dokumen. Partisipan penelitian ini berjumlah 44 orang terdiri dari dokter penanggung jawab pelayanan (DPJP), perawat, bidan dan tim casemix termasuk koder yang memenuhi kriteria inklusi. Triangulasi juga dilakukan kepada peneliti fraud, BPJS Kesehatan dan Pusat Pembiayan Jaminan Kesehatan Kementerian Kesehatan. Analisa data menggunakan metode Moustakas dengan tahapan reduksi dan eliminasi data, tematisasi data, deskripsi tekstural, deskripsi structural dan sintesa data. Hasil penelitian menemukan bahwa skema fraud jaminan kesehatan di rumah sakit yaitu fraud terkait dengan penegakan diagnose dan tindakan medis, pemeriksaan penunjang, koding diagnose, iur biaya, peserta, pengajuan klaim, rujukan pasien, rawat jalan dan rawat inap, manajemen rumah sakit, dan kebijakan BPJS Kesehatan. Pelaku fraud jaminan kesehatan di rumah sakit adalah pihak manajemen rumah sakit, pemberi pelayanan di rumah sakit, pengelola klaim rumah sakit, peserta atau pasien dan BPJS Kesehatan. Penyebab fraud jaminan Kesehatan pada SDM di rumah sakit terdiri dari faktor internal dan faktor eksternal. Faktor internal terkait dengan human capital yaitu individual motivation, individual capability, organizational climate, leadership dan workgroup effectiveness. Faktor ekternal terdiri dari regulasi JKN, sistem pembiayaan JKN dan sistem BPJS Kesehatan. Dampak negatif fraud jaminan kesehatan di rumah sakit yaitu dampak terhadap SDM berupa sanksi hukum, sanksi sosial, kerusakan moral, sanksi keuangan dan sanksi profesi. Dampak terhadap rumah sakit berupa reputasi rumah sakit, sanksi keuangan, pelayanan rumah sakit, lingkungan kerja rumah sakit dan budaya kerja rumah sakit. Dampak terhadap pasien yaitu merugikan pasien dan keluarganya serta pelayanan pasien yang buruk. Pencegahan fraud jaminan kesehatan pada SDM di rumah sakit dapat dilakukan dengan pendekatan teori tebus regulasi yang merupakan representasi dari human capital. Tebus adalah representasi pencegahan internal rumah sakit yaitu: a) organizational climate: tata kelola manajemen tata kelola klinis, kendali mutu kendali biaya, deteksi, pelaporan dan sanksi, perbaikan mekanisme klaim, dan budaya anti fraud; b) leadership; c) individual capability (edukasi anti fraud); d) individual motivation (sistem insentif); e) workgroup effectiveness (penguatan tim casemix dan pembentukan tim anti fraud rumah sakit). Regulasi adalah representasi pencegahan eksternal terdiri dari: a) perbaikan regulasi JKN; b) perbaikan sistem pembiayaan JKN; c) perbaikan sistem BPJS Kesehatan; dan d) Tim anti fraud independen. Kebaruan penelitian ini adalah teori tebus regulasi dalam pencegahan fraud jaminan kesehatan pada SDM di rumah sakit. Kata kunci: modal manusia, fraud, jaminan kesehatan nasional ************ The purpose of the study was to find the essence of the experience of HR in hospitals against fraud in the health insurance program. This research design uses a qualitative method with a phenomenological approach. Data collection methods were conducted through interviews, focus group discussions (FGD) and document studies. The participants of this study were 44 people consisting of doctors in charge of services (DPJP), nurses, midwives and the casemix team including coders who met the inclusion criteria. Triangulation was also carried out on fraud researchers, BPJS Health and the Health Insurance Financing Center of the Ministry of Health. Data analysis used the Moustakas method with stages of data reduction and elimination, data thematization, textural description, structural description and data synthesis. The results of the study found that the fraud scheme of health insurance in hospitals, namely fraud related to the enforcement of medical diagnoses and actions, supporting examinations, diagnosis coding, fee contributions, participants, claim submissions, patient referrals, outpatient and inpatient care, hospital management, and policies BPJS Health. Perpetrators of health insurance fraud in hospitals are hospital management, hospital service providers, hospital claims managers, participants or patients and BPJS Health. The causes of health insurance fraud on HR in hospitals consist of internal factors and external factors. Internal factors related to human capital are individual motivation, individual capability, organizational climate, leadership and workgroup effectiveness. External factors consist of JKN regulations, the JKN financing system and the BPJS Health system. The negative impact of health insurance fraud in hospitals is the impact on HR in the form of legal sanctions, social sanctions, moral damage, financial sanctions and professional sanctions. The impact on hospitals is in the form of hospital reputation, financial sanctions, hospital services, hospital work environment and hospital work culture. The impact on patients is detrimental to patients and their families as well as poor patient care. Prevention of health insurance fraud on HR in hospitals can be done with tebus regulasi theory which is a representation of human capital. Tebus is a representation of hospital internal prevention, namely: a) organizational climate: clinical governance, quality control, cost control, detection, reporting and sanctions, improvement of claim mechanisms, and anti-fraud culture; b) leadership; c) individual capability (anti fraud education); d) individual motivation (incentive system); e) workgroup effectiveness (strengthening the casemix team and establishing the hospital's anti-fraud team). Regulasi is a representation of external prevention consisting of: a) improvement of JKN regulations; b) improvement of the JKN financing system; c) improvement of the BPJS Health system; and d) Independent anti fraud team. The novelty of this study is the tebus regulasi theory in preventing health insurance fraud on HR in hospitals.

Item Type:	Thesis (Doktor)
Additional Information:	1). Prof.Dr. Dedi Purwana, E.S., M.Bus ; 2). Dr. Choirul Anwar, MBA., MAFIS., CPA
Subjects:	Manajemen > Manajemen Sumber Daya Manusia
Divisions:	PASCASARJANA > S3 Ilmu Manajemen
Depositing User:	Users 13406 not found.
Date Deposited:	26 Feb 2022 00:57
Last Modified:	26 Feb 2022 00:57
URI:	http://repository.unj.ac.id/id/eprint/22683

Actions (login required)

View Item