Master of Law, Postgraduate Program, Universitas Pembangunan Panca Budi, Indonesia.
Research Article
World Journal of Advanced Research and Reviews, 2024, 23(02), 1235-1240
Article DOI: 10.30574/wjarr.2024.23.2.2429
Received on 01 July 2024; revised on 12 August 2024; accepted on 14 August 2024
The Indonesian government created a system in an effort to achieve health insurance for all Indonesian people, namely the National Social Security System (SJSN). The National Health Insurance Program (JKN) is a manifestation of the implementation of Law Number 36 of 2009 concerning Health. The Social Security Administering Body (BPJS) for Health as the manager of the JKN program is regulated in Law Number 24 of 2011 concerning the Social Security Administering Body. The Social Security Administering Body (BPJS) for Health uses the latest version of INA-CBG's (Indonesia Case Based Groups) rates, namely version 4.0, in the National Health Insurance (JKN) payment pattern. The INACBG rate really depends on the diagnosis made during the patient's treatment at the health service facility. In practice, doctors will establish primary and secondary diagnoses, as well as actions and examinations carried out on patients, which will then be given a diagnosis code by the medical record coder. Writing diagnosis codes is an important part of the process of managing health information in hospitals or other health service facilities. Diagnosis codes are used to record and classify patient diagnoses, making it easier to manage patient data, provide medical care, research, and also insurance claims. Inaccuracy of diagnosis codes will have an impact on health service costs. Related to this, if the coder is not precise and accurate in codifying the disease, it will have an impact on the quality of claim payments. Upcoding is changing a diagnosis and/or procedure code to a code that has a higher rate than it should. There are several factors that cause upcoding to occur. It is important for Follow-up Referral Health Facilities (FKRTL) to take preventive measures to prevent Upcoding from occurring through the efforts mentioned in PMK No. 16 of 2019. If Upcoding or other types of circumstances (Fraud) occur, the authorized agency can impose administrative sanctions starting from verbal warning up to the revocation of the operational permit from the FKRTL.
Writing excessive diagnosis codes; Upcoding; Fraud; Prevent; Referral Health Facilities (FKRTL); PMK number 16 of 2019
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Danne Maryana and Henry Aspan. Juridical analysis of excessive diagnostic code writing (upcoding) reviewed from the regulation of the minister of health number 16 of 2019. World Journal of Advanced Research and Reviews, 2024, 23(2), 1235-1240. Article DOI: https://doi.org/10.30574/wjarr.2024.23.2.2429