Jakarta, BERITATERKINI.CO.ID | Komisi Pemberantasan Korupsi (KPK) Republik Indonesia (RI) menyampaikan paparan hasil kajian KPK pada sektor kesehatan, yaitu mengenai kajian tata kelola Dana Jaminan Sosial (DJS) Kesehatan, Sabtu (14/3/2020).
Kajian KPK didasarkan pada beberapa indikator, diantaranya ; keterlambatan pembayaran klaim ke fasilitas kesehatan (Fases), Koletabilitas iuran hanya 50% pada segmen peserta mandiri, defisit yang semakin meningkat, pada 2018 mencapai Rp. 12, 2 Triliun, dalam kegiatan piloting bersama penanganan fradu JKN pada 2018, ditemukan froud pada proses klaim.
Kajian KPK dimaksudkan untuk mengatasi defisit BPJS kesehatan dari sisi efisiensi pengeluaran BPJS kesehatan, yaitu Adverse selection dan Moral Hazard peserta mandiri, over-payment karena kelas rumah sakit yang tidak sesuai, froud di lapangan.
Karena itu, KPK memberikan sejumlah rekomendasi kepada Kementrian kesehatan dan BPJS kesehatan untuk menutupi defisit. Rekomendasi KPK untuk Kemenkes agar mempercepat pedoman Nasional praktik kedokteran (PNPK) esensial dari target jenis PNPK. Juli 2019 baru tercapai 32 PNPK. Opsi pembatasan manfaat untuk penyakit Katastropik, akibat gaya hidup seperti jantung, diabetes, kanker, stroke dan gagal ginjal. Total claim penyakit Katastropik pada 2018 sebesar Rp. 94 Triliun. Mengakselerasi coordination of benefit dengan asuransi kesehatan swasta, Kemenkes mengimplementasikan co-payment 10% sesuai Permenkes No 51 Tahun 2018 dengan co-payment 10%.
Evaluasi penerapan kelas rumah sakit, hasil ploting pada 2018 mendapatkan 4 dari 6 rumah sakit tidak sesuai kelas sehingga mengakibatkan pemborosan pembayaran klaim sebesar Rp. 33 Miliyar per-tahun.
Hasil riview Kemenkes 2018 dari 7 Ribu rumah sakit ditemukan 898 rumah sakit yang tidak sesuai kelas, jika dilakukan perbaikan penetapan kelas terdapat estimasi penghematan beban jaminan BPJS kesehatan sebesar Rp. 6,6 Triliun, sehingga penghematan pengeluaran claim sebesar Rp. 12, 2 Triliun.
Tindak lanjut pada verifikasi claim untuk mengatasi fradu di lapangan berupa, administrasi (pengembalian claim), perdata (pemutusan kontrak kerjasama) dan pidana. (Hmskpk/BRT)
Editor ; Dik Eno
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