Hasna Medika Group, a leading heart hospital network in Indonesia with 13 branches, offers comprehensive cardiology services and pharmaceutical support. The group engages in B2B transactions with insurance companies and BPJS Kesehatan for integrated financing, as well as B2C transactions providing services directly to patients.
Project Executive Summary
Audit findings
This project audited 739,647 pharmacy transactions across Hasna Medika Group’s hospital network to assess formulary compliance and cost efficiency under the BPJS reimbursement scheme. The analysis identified a Rp 188 billion claim eligibility gap caused by misalignment between formulary drugs and INA-CBGs coverage, an 82.8% compliance rate that still generates material financial leakage at scale, and procurement price disparities across 174 identical drug items.
The Challenge
Root causes of leakage
The Protocol
BPJS Patient + Generic Formulary
Fully covered by national insurance. Zero cost impact to hospital inventory.
The Anomaly
BPJS Patient + Generic Formulary
Financial leakage. The hospital is bearing the cost of covered medication.
The data revealed a striking departure from the intended protocol. While the billing rules dictated that BPJS-covered medications should be cost-neutral, thousands of records showed residual COGS being absorbed by the hospital—a silent drain on operational margins.
Standard reporting failed to isolate whether the root cause was prescribing behavior (Clinical) or procurement inconsistency (Logistics). Data integrity issues, particularly Unit-of-Measure (UoM) reporting errors, further distorted financial statements and replenishment cycles.
Strategic Solution
Data-driven intervention
Interactive Simulation: The Leakage Lever
Currently, our generic prescribing compliance rate stands at 82.8%. By driving this compliance upward, we can significantly reduce unnecessary inventory costs (COGS).
Each leaked prescription costs the hospital an average of Rp 87,500.
*Drag the gold numbers above to simulate financial impact.
Understanding the Model
The Logic
This simulation uses actual audited data from 739,647 records. The formula calculates the financial gap where generic medications incur hospital costs (COGS > 0) despite being covered by BPJS.
Formula: (Monthly Volume × Non-Compliance %) × Avg Cost per Leak = Monthly Potential Loss.
How to Use
- Compliance: Drag to simulate improvements in clinical prescribing behavior. 100% means zero leakage.
- Avg Leak (HPP): Adjust the cost impact per non-compliant item to see risk sensitivity.
- Annual Benefit: Shows the recovered portion of the initial IDR 11.1B annual loss.
This solution offers an interactive audit environment that identifies areas where pharmacy costs are being wasted and estimates the potential for realistic recovery.
"It analyzes prescription, procurement, and billing data to reveal which generic prescriptions are not reimbursed, their cost to the hospital, and the sources of price discrepancies for the same drugs."
By implementing small improvements in generic prescribing and procurement practices, the system estimates potential annual savings of up to Rp 5.7 billion and provides a comprehensive, consistent view of over 700,000 transactions, enabling teams to take targeted corrective action without compromising clinical care.