The increasing of the awareness of people in using health care insurance, also raise the bad action of parties to try obtaining the maximum benefit in the process of health care insurance. Because of the desire to obtain such benefits then there are inevitable occurrence to do the action that are not in accordance with the applicable provisions or fraud or abuse in health care insurance practices.
Based on the experience of health insurance companies in the United States, fraud and abuse in health insurance can reach 10% of the total health care costs each year.
In the known existence of health insurance claims filed by participants individually to insurance companies and other forms of insurance are filing the claim made by the institution by the health providers. Surely these two forms of filing a claim even this is not a possibility that the fraud happens so that it can cause losses to the insurance company.
In the health insurance we recognize the existence of three parties that are interconnected that the participants as beneficiaries, health providers as the party providing the service in accordance with the benefits that the rights of participants and insurance companies as those who manage the financing of such benefits. In conjunction with the implementation of social insurance, especially health insurance, then the Government acts as the regulator and has a very large role.
Fraud in the health care services (provider) referred to as a form of a deliberate effort made to create a benefit that should not be enjoyed either by individuals or institutions and can harm others. According to the National Health Care Anti-Fraud Association's (NHCAA) states that "Health care fraud is an intentional Deception or misrepresentation That the individual or entity makes knowing That the misrepresentation Could result in some unauthorized benefit to the individual or the entity or to some other party. "
Fraud in the health care services conducted on something or circumstances and situations related to the health service, health care coverage or benefits and financing.
In health care, also known referred to as other forms of abuse that can harm the health service. However, this term is more widely used in health insurance is defined as activities or actions that harm the health care service but not included in the category of fraud. Abuse can be either malpractice or over utilization.
