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This study is motivated by the increasing complexity of financing coordination between the National Health Insurance (BPJS Kesehatan) and supplementary health insurance providers under the Coordination of Benefits (KAPJ) scheme, which creates potential claim disputes and administrative risks for hospitals. Although Minister of Health Decree No. HK.01.07/MENKES/1117/2025 regulates payment allocation and membership verification mechanisms, it does not explicitly recognize pre-admission confirmation as a preventive legal protection instrument. This research aims to analyze the normative position of pre-admission confirmation within the KAPJ framework, conceptualize it as a preventive legal protection mechanism, and formulate a proportional implementation model. The study employs a normative juridical method using statutory and conceptual approaches through literature review of relevant regulations and scholarly works. The findings indicate that pre-admission confirmation possesses implicit normative legitimacy through membership verification obligations and system integration requirements, and functions as a risk allocation mechanism that clarifies payment responsibilities prior to service delivery. Its implementation enhances legal certainty, reduces fraud potential, and minimizes claim disputes, provided that access to emergency medical services remains guaranteed.

Although JKN aims to provide equitable and quality health services, fraudulent practices, such as phantom billing and diagnosis manipulation, continue to grow, harming BPJS Kesehatan and participants. This study aims to examine the effectiveness of legal sanctions against JKN claim fraud in FKRTL and identify gaps in their implementation. Although regulations are in place, law enforcement remains weak, with administrative sanctions failing to provide sufficient deterrence. The gap in this research lies in the lack of application of criminal sanctions in fraud cases, especially in existing regulations. The novelty of this research is its comparative approach between current administrative sanctions and the potential application of criminal sanctions in the context of healthcare fraud. The research method uses a normative-descriptive approach, analyzing regulations and fraud audit results, and identifying gaps in the implementation of legal sanctions. The results of the study indicate that strengthening criminal sanctions and integrating technology in claim monitoring can increase the effectiveness of fraud prevention. These findings are expected to strengthen regulations and improve the integrity of the JKN system, as well as provide policy recommendations for more effective law enforcement.