DPR Comments On BPJS Fictitious Claims: This Is A Bad Record, Naughty Hospitals Must Be Dealt With Firmly!

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JAKARTA - The DPR has highlighted allegations of fraud by a number of hospitals (RS) by making false claims of health costs to the Health Social Security Administration (BPJS) so that it is detrimental to the state. Commission IX of the DPR requested law enforcement and system evaluation, including tightening supervision.

"The alleged fictitious claim by BPJS Kesehatan carried out by the hospital must be thoroughly investigated. Strict action by rogue hospitals that are proven to have committed criminal violations is because it is not only detrimental to the state, but also detrimental to the community," said Commission IX member Rahmad Handoyo, Wednesday, September 25.

Previously, a joint team from the Corruption Eradication Commission (KPK), the Ministry of Health (Kemenkes), BPJS, and the Financial and Development Supervisory Agency (BPKP) found three private hospitals that submitted fictitious claims, causing state losses of up to tens of billions of rupiah in 2022-2023.

From the KPK's investigation, a fictitious claim scandal or phantom billing was found in 3 hospitals in Central Java and two in North Sumatra. According to the KPK, at least from one hospital that filed a fictitious claim, there were 8 perpetrators, including hospital owners because the health facility was private.

Even the fraud profit in the fictitious BPJS claim case is also said to have flowed to the family of the hospital owner, to the doctor who helped cheat. Rahmad said this should not happen again.

"This is a bad record in our world of health. If actions like this are allowed and not dealt with firmly, it will be a bad precedent. We ask that the case be handled seriously immediately," he said.

Furthermore, Rahmad encouraged the Government to conduct a comprehensive audit of all hospitals in collaboration with BPJS Kesehatan. This is to find out whether there is a fraud carried out by the hospital other than the 3 hospitals.

"A thorough audit is also so that we know where the weakness of the BPJS Health system is. Also make sure to tighten supervision in the BPJS implementation system so that health services really take sides with the community and provide proper health insurance," said Rahmad.

Rahmad said efforts to improve BPJS Kesehatan were not only the responsibility of BPJS, but also required the active role of all parties, including the Government, supervision of the DPR, law enforcement, supervisory bodies in the health and financial sectors, to community participation.

"We all have a responsibility to ensure that the national health insurance provided by the state can really be enjoyed by all Indonesian people, without exception," said the legislator from the Central Java V electoral district.

The mode that is widely used by three hospitals in this case is to increase BPJS Health claim bills. Including by plagiarizing other patient claims and increasing the number of drugs used in claim reports.

The rogue hospital management committed various frauds such as manipulating diagnosis and/or actions, plagiarizing claims from other patients (cloning), false claims (phantom billing), inflating drug bills and/or medical devices (Inflated bills), breaking service episodes that are not in accordance with medical indications, and others.

"With this manipulation, the community is directly harmed. Because if there are actions that are not covered by BPJS, the patient must bear additional costs. The state loses, the community also loses. It becomes a double kill," said Rahmad.

The member of the House of Representatives' health commission also questioned the monitoring system carried out by BPJS so far. According to Rahmad, the lack of supervision has caused a lot of manipulation.

"The BPJS Kesehatan must immediately improve so that something like this does not happen again. The criteria and requirements that are too many and long are not only troublesome for people who are in need of medical assistance, but also open up gaps in the potential for fraud or manipulation," he said.