Factors affecting potential overpayment claim of government health insurance in naval hospital

Abstract

Background: There are the potential overpayment claims performed by hospital. The aims of the study were to find out what the factors causing potential overpayment. 
Methods: This study was descriptive analytic to all document after audited by internal oversight unit for national health insurance (BPJS). The population was all claim documents after audited by internal audit BPJS in 2018.
Results: The results showed that there were 3881 (1.33%) potentially overpaid documents found during 2018. The value of overpayment was approximately IDR 4,066,938,800 (1.18%) of total claim BPJS in 2018. Factors affecting overpayment claim of BPJS insurance were: readmission, double billing for inpatients and outpatients on the same day, differences in perception of diagnoses and procedures in coding, different classes of care with patient rights, billing of died patient, and chemotherapy patients.
Conclusion: The potential for overpayment can be resulted from both hospital and BPJS sides associated with difference of perception.

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