The National Health Insurance (JKN) Program is one of national strategic programs mandated by Indonesian Law managed by BPJS Kesehatan aimed to provide health insurance for all Indonesian citizens. The number of JKN participants as of May 1, 2018, has reached 196.62 million. The primary issue faced by this program is the high number of visiting participants to branch offices for administrative matters. Dissatisfaction towards long waiting times caused participation satisfaction index to decline since 2014 to 2016.

After a year of Indonesia’s national health security program (Jaminan Kesehatan Nasional or abbreviated as JKN), in 2015 BPJS Kesehatan instituted Pay for Performance (P4P) scheme in the capitation system for primary care providers. P4P in Indonesia is named Kapitasi Berbasis Komitmen Pelayanan (KBK) or Commitment-Based capitation, as means to designate commitment of primary care providers to deliver primary care services comprehensively. Unfortunately, resistance from primary care providers hindered its full execution.

Fraud incidence in healthcare is not easy to find. As a country that only started Social Health insurance (JKN program) since 2014, there are not many parties that provide fraud detection tools for INA CBG case-mix system. In addition, the law that establishes an investigation for potentially fraudulent incidents is still being drafted. On the other hand, there is a significant increase in the JKN’s participants & in the number of claims. By the end of 2017, the number of claims submissions were 80,641,271 cases.

Health Facilities Information System (HFIS) is a platform developed by BPJS Health of Indonesia to improve contracting accountability and referral system efficiency. Before HFIS, contracting mechanism was done and monitored manually which did not only time consuming but also sparked dissatisfaction from providers. Referral from a health facility to another was also not based on sufficient information about the availability of medical specialist or facilities of the referral hospitals.

Increasing number of Indonesia Health Insurance Program participants has greatly impacted on the increasing utilization of service and the number of claim reimbursement of BPJS Health. This change required a large number of additional resources and staff for claim administration processing. BPJS Health then launched an initiative to simplify claim processing and management so that less resources are needed. The initiative was named VEDIKA which is short for Digital Claim Verification, a digital application for the claim verification process for secondary health facility reimbursement.

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