Indonesia’s BPJS Kesehatan looks to integrated health records to detect insurance fraud
Indonesia’s social health insurance agency is moving towards electronic medical record-based claims checks to streamline verification and detect potential fraud, says BPJS Kesehatan's IT Director, Setiaji.
BPJS Kesehatan is moving towards claims verification based on EMRs, integrated through SATUSEHAT, to speed up checks and detect potential fraud across thousands of healthcare facilities. Image: Canva
Previously, electronic medical records must be manually saved, printed and sent to Indonesia’s social health insurance agency, BPJS Kesehatan, to review before insurance claims can be processed.
The integration of electronic medical records (EMRs) into the Ministry of Health (MOH)’s digital health platform, SATUSEHAT, tackles this challenge by enabling facilities to share medical data in a structured format.
This supports the claims verification under the National Health Insurance programme (JKN).
Speaking to GovInsider, BPJS Kesehatan's Director of Information Technology, Setiaji, says that hospitals that already have a Hospital Management Information System and EMRs but still send reports to BPJS Kesehatan as PDFs show that “something has become disconnected.”
To close this gap, a joint circular issued on July 30 by MOH, BPJS Kesehatan, and several other ministries and agencies encourages hospitals to move away from hard copy claims towards electronic claims based on EMR data.
According to Setiaji, the new approach will allow different healthcare systems to connect and exchange information. This should simplify claims verification and help flag data discrepancies that could point to potential fraud.
Connecting patient data across healthcare facilities
EMR integration is not just about the ease of administering claims, but could also let healthcare facilities see a patient’s full medical history by accessing records from other providers.
“Just enter the Population Identification Number (NIK), and the Master Patient Index appears immediately,” says Setiaji.
However, integration does not mean that all administrative procedures will disappear.
Patients still need to follow the registration process at the facility they visit, while the benefits of information exchange for professionals and patients depends on the completeness of medical records and how access is managed, he notes.
Setiaji explains that patients can give consent to their treating doctors to access their medical information under the new rules.
Integrated data can help detect potential fraud
Setiaji highlights that BPJS Kesehatan receives around two million claims a day from both primary and advanced healthcare facilities. With around 1,000 verifiers, reviewing claims at this scale presents a significant operational challenge.
Integrating EMRs through SATUSEHAT also helps BPJS Kesehatan compare information about healthcare services with the claims submitted by healthcare facilities.
Setiaji says the verification process involves checks across 18 types of data, including visits, diagnoses, medication, radiology, and hospitalisation.
This information can help identify discrepancies between the services recorded and the claims submitted.
“For example, a diagnosis that does not match the patient’s condition. Adding a diagnosis to increase the claim value can be an indication of potential fraud.”
Artificial intelligence (AI) could further strengthen this process by helping to review documents and flag information requiring closer examination.
"With the ability to read a document in less than a second, AI is expected to help verifiers identify claims that do not meet the required criteria," he adds.
However, he emphasises that each finding still requires further investigation to determine whether the discrepancy genuinely indicates a problem with the claim.
Setiaji explains that AI could also reduce claims processing times compared with current procedures.
With implementation having begun only recently, its effectiveness still needs to be demonstrated through an evaluation of the rollout.
Data standardisation is key
BPJS Kesehatan works with around 20,000 healthcare facilities, which use different information systems and have varying levels of technological readiness.
“The main challenge is standardisation. The reason it [has not worked] before was that there has been no standardisation,” he says.
To address this, the adoption of standards that support structured health data exchange through Fast Healthcare Interoperability Resources (FHIR) is a key focus.
Standardisation covers diagnosis codes, medication, radiology and laboratory tests, ensuring that information from different facilities carries the same meaning when processed by receiving systems, he said.
This is essential to detect potential fraud. While systems can flag discrepancies between service records and claims, these findings are only useful when the underlying information is sufficiently complete and consistent.
Infrastructure readiness across healthcare facilities also affects implementation.
Setiaji says around 700 of Indonesia’s 10,200 community health centres (puskesmas) lack access to the internet and electricity.
To support healthcare facilities in areas without adequate connectivity, the MOH has a programme to provide Starlink satellite internet services.
Meanwhile, BPJS Kesehatan provides support through regional information technology teams, a helpdesk, and a sandbox environment where facilities can test their systems using simulated data.
Healthcare facilities can also take part in a three-day Connectathon, a hands-on testing event where healthcare systems prove they can exchange data using FHIR standards, to test connectivity and resolve technical issues.
