POJK 36/2025 Drives TPA Companies to Strengthen Data-Based Clinical Governance
The issuance of Financial Services Authority (OJK) Regulation No. 36 of 2025 marks a significant milestone in strengthening clinical governance within the insurance industry’s healthcare services. The regulation requires insurance companies to ensure three key aspects: adequate medical capability, digital capability for data-based oversight, and the existence of an independent and competent Medical Advisory Board.
In response to this policy, PT Administrasi Medika (AdMedika), a Third Party Administrator (TPA) with an extensive healthcare service network across Indonesia, has affirmed its commitment to strengthening data analytics-based clinical governance through the reinforcement of its Medical Advisory Board (MAB) function. AdMedika stated that it already possesses a strong technological foundation and extensive experience in managing integrated healthcare claims.
The strengthening of the MAB is designed to address OJK regulatory requirements, particularly regarding medical and digital capability aspects. On the medical side, the MAB is supported by Medical Advisors and a Utilization Review Team with professional backgrounds in healthcare. These teams conduct cost analysis and service suitability evaluation to ensure cost-effectiveness and cost efficiency principles in healthcare delivery.
On the digital front, the service review process has been integrated with data analytics systems, real-time dashboards, and artificial intelligence-based transaction analysis. This system enables the identification of claim patterns, service utilisation trends, and potential service irregularities with greater speed and accuracy.
In strengthening clinical governance, AdMedika has engaged numerous medical professionals, including Agus Purwadianto, who serves as ethico-medicolegal adviser to the MAB, whilst retired Major General TNI Agus Yunianto heads the MAB alongside a team consisting of various medical specialisations. This collaboration is expected to ensure that each medical recommendation issued has a strong ethical, academic, and clinical practice foundation.
Additionally, the MAB strengthening is marked by collaborative service operations with 13 partner insurance companies: Generali Indonesia, AIA Financial, Asuransi Central Asia, Sequis Life, Great Eastern Life Indonesia, AXA Mandiri Financial Service, Tokio Marine Life Indonesia, Car Life Insurance, Asuransi MAG, Panin Dai-Ichi Life, Dayin Mitra, Askrida Syariah, and Staco Mandiri.
AdMedika Chief Executive Officer Dian Prambini stated that digital system support and data analytics are important factors in accelerating the healthcare service evaluation process.
“With data analytics support, the Medical Advisory Board can conduct evaluation and medical decision-making in a more objective, accurate, and responsive manner,” Dian stated.
According to Dian, this approach enables the creation of balance between improving healthcare service quality and prudent principles in medical cost management. Through strengthening the data analysis-based Medical Advisory Board, the company hopes that clinical governance implementation can support compliance with POJK 36/2025 whilst ensuring medical decisions align more closely with clinical indications, service transparency, and sustainability of the healthcare system for insurance participants.