Jakarta. State health insurer BPJS Kesehatan recently held a competition to test its employees’ clinical coding and utilization review skills.

The competition, dubbed the Clinical Coding and Utilization Review Olympiad (OCCUR), recently held its grand finals. According to BPJS Kesehatan’s health service guarantee director Lily Kresnowati said that the aforementioned skills were key in the delivery of the national health insurance scheme JKN.

“The accuracy in diagnosis and clinical coding significantly determines the amount of service fees paid to healthcare facilities. Utilization reviews are pivotal in detecting potential discrepancies and preventing fraud in services," Lily was quoted as saying in a press statement.

This prompted BPJS Kesehatan to improve the competency of the healthcare verifiers and anti-fraud staff through the OCCUR Olympiad, which has entered its third year.

"Verifiers and anti-fraud staff are at the forefront of ensuring healthcare financing is effective, efficient, and free from irregularities. They are not just administrative examiners. These two roles are key to maintaining claim accuracy, financing efficiency, and ensuring services provided to JKN participants comply with regulations and medical rationality," Lily explained.

The 2025 OCCUR had the country’s best verifiers and anti-fraud staff in attendance. They all had to undergo a tough selection process. The competition tested the participants on their ability to read case records, determine diagnosis codes and procedures based on ICD standards, and analyze the rationale for services through a utilization review approach.

"Improving the competency of verifiers and anti-fraud staff is a strategic investment to maintain the sustainability of the JKN program. Quality healthcare services begin with an accurate, transparent, and accountable payment system," Lily said.

The 2025 OCCUR also showcased over 50 scientific papers from BPJS Kesehatan’s “ambassadors”, which mainly consist of verifiers and anti-fraud staff. The papers highlighted innovations in claims verification mechanisms, improving the quality of service data, and strengthening early detection systems for potential fraud in healthcare facilities.

“Their papers show how the BPJS Kesehatan Ambassadors not only work technically, but they also think critically and provide solutions in developing a more adaptive and integrated financing system," Lily said.

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