Principally, the insurance business is a business based on trust. The trust was among the participants of insurance or consumer to a physician or Health Care Providers. Trust between the participants of the insurance company that has been agreed that the benefits will be actually obtained by health care insurance participants. Yet, it often also cause imbalance because the insurance company that determines all the provisions that must be followed by the participants. Trust also among the insurers against the Health Services Providers in the hope that the service provided to satisfy the participants so that will give a positive impact both to the Health Services Providers and insurance companies. With this basic of the actual trust and practices, the fraud problem can be overcome if the trust is maintained between the three parties.
Because fraud in health care insurance is an activity or action that could give an enormous impact in health care financing, so it is a necessary efforts to prevent fraud. Based on the experience of many developed countries, fraud can be prevented by among others the role of all concerned Government:
- Establish provisions of law or statute of fraud that lists about the punishment that can be imposed on those who do fraud.
- Besides, the Government needs to establish standards of care, standard therapy, standard drugs and medical devices that can be reference in all measures of health care. Thus, the existence of fraud can be traced based on the provisions that have been defined.
Health Services Providers:
- Health Services Providers should maintain the trust of insurance companies against the service provided and embodied in the form of claims that appropriate to services provided and accurate.
- Health Services Providers should maintain the trust of patients or participants of insurance by providing health care in accordance with a predetermined the standards and benefits that have been the rights of participants as well.
Insurance participants:
- Equip participants with the actual identity as and does not provide opportunities for misuse by unauthorized.
- Request information on services provided by the Health Service, doctors and nurses.
Insurance companies:
- Routine investigation of claims filed against randomly by cross-checking against the medical record.
- Consultation to the Medical Advisory Soard (MAS) to claims filed or the type of action and therapy given by the provider. Besides MAS can act as a party providing a second opinion on actions that will be given to patients Giver of Health Services.
With the progressive development of health insurance in the world will possess cases of health care insurance fraud and abuse should be a common concern. Increased health care costs that occur only because the result of fraud should be avoided. Therefore the participation of all stakeholders is crucial to take precautions and reduce the likelihood of such fraud.
