The vision of BPJS Kesehatan is to achieve universal coverage within 5 years (2014-2019). Because of this, BPJS Kesehatan needs to prepare itself in minimizing all risks that delay the achievement of the target; which of course comes in many forms. Risk Management in BPJS Kesehatan is based on the BPJS Kesehatan Director’s Regulation Number 46 of 2017 regarding BPJS Kesehatan Integrated Risk Management Guidelines in order to fulfill the international risk management standard ISO 31000.

Since transformation of PT Askes (Persero) to BPJS Kesehatan in 2014, the interest of the people participate in JKN KIS (National Health Social Security) has grown.The excellent service in Branch Offices is far from perfect due to the long queues and a lack of uniformity of the service counters in the Branch Offices. In June 2016, BPJS Kesehatan made a new innovation in the form of the CSTI (Customer Service Time Index) Application as a service and wait time measure and the SUPEL (Customer Voice) application as a measurement for excellent service performance of frontliner.

Since the start of BPJS Kesehatan in January 1 2014, till May 1 2018 the coverage of participants are 197 million, there were highnumber of visits to the Branch Offices. During the participants registration process, there were an average of 70.000-100.000 visits every day all Branch Offices in Indonesia wide (average per Banch Office is 700-1000 visits), meaning that there was no certainty regarding the queues and service times for the participants.

Kader JKN program is a partnership program that involves the general public to care about social health care program. Every social healthcare provider has limitation and challenges. We must be smart to optimize another resource around us. By creating Kader JKN program, BPJS Kesehatan can manage and solve the limitation of its resources to collect premium collection of individual/ informal member and switching the challenge to be an opportunity. Since it started on April 2017, BPJS Kesehatan can increase the collectability of individual/informal segment about thirteen point nine percent.

The Family Virtual Account (FVA) system is a system which combines enrollee bills in a family. This system has great benefits for the enrollee such as more efficient payments, the prevention of adverse selection for BPJS Kesehatan and the improvement collection of contribution from the informal workers segment. In the implementation of this system, Indonesia’s Social Health Insurance Funds (BPJS Kesehatan) must coordinate well with the Ministry of Internal Affairs as the managers of the population data and must also improve the promotion of the FVA system to the public.

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.