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All Journal TELKOMNIKA (Telecommunication Computing Electronics and Control) Jurnal Ilmiah Kursor Jurnal Teknologi Informasi dan Ilmu Komputer International Journal of Advances in Intelligent Informatics EMITTER International Journal of Engineering Technology KLIK (Kumpulan jurnaL Ilmu Komputer) (e-Journal) JOIV : International Journal on Informatics Visualization Jurnal RESTI (Rekayasa Sistem dan Teknologi Informasi) Bina Insani ICT Journal Kinetik: Game Technology, Information System, Computer Network, Computing, Electronics, and Control INOVTEK Polbeng - Seri Informatika Technomedia Journal Applied Technology and Computing Science Journal Building of Informatics, Technology and Science GUYUB: Journal of Community Engagement Informatics, Electrical and Electronics Engineering Journal Of Artificial Intelligence And Software Engineering Jurnal Informatika: Jurnal Pengembangan IT El-Mujtama: Jurnal Pengabdian Masyarakat The Indonesian Journal of Computer Science
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Politeknik Elektronika Negeri Surabaya
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Journal : Building of Informatics, Technology and Science

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Analisis Kinerja Algoritma Machine Learning Untuk Klasifikasi Potensi FRAUD Klaim Layanan Kesehatan Rumah Sakit Ubed, Imanullah Ali; Syarif, Iwan; Saputra, Ferry Astika
Building of Informatics, Technology and Science (BITS) Vol 7 No 1 (2025): June (2025)
Publisher : Forum Kerjasama Pendidikan Tinggi

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47065/bits.v7i1.7349

Abstract

Fraud in healthcare claims represents a critical challenge that undermines the efficiency and sustainability of Indonesia's National Health Insurance (JKN) system. This study contributes a large-scale comparative evaluation of five machine learning algorithms for classifying potential fraud in BPJS Kesehatan claims, namely Artificial Neural Network (ANN), Support Vector Machine (SVM), Random Forest (RF), XGBoost + SMOTE, and Logistic Regression (LR). A novelty of this study lies in applying the SMOTE technique in conjunction with XGBoost to address class imbalance in fraud datasets. The dataset consists of over 200,000 claim entries, which have undergone data cleaning, normalization, and feature selection. Performance was assessed using precision, recall on fraud class (positive), f1-score, accuracy, and confusion matrix visualizations to capture classification error distribution. Results demonstrate that ANN and XGBoost + SMOTE are superior in detecting fraudulent claims with high recall, while SVM achieves the most balanced performance in terms of precision and sensitivity. Random Forest and Logistic Regression serve as moderate baselines but are less effective in identifying complex fraud patterns. This study contributes to the development of a more adaptive and efficient fraud detection system based on machine learning, with practical implications for strengthening the automatic verification system used by BPJS Kesehatan.
Co-Authors Adam Prugel-Bennett Afifah, Izza Nur Agung Muliawan Ahsan, Ahmad Syauqi Aidil Saputra Kirsan Aji , Rendra Suprobo Al Falah, Adam Ghazy Alfaqih, Wildan Maulana Akbar Ali Ridho Barakbah Alwan Fauzi Amalia Wirdatul Hidayah Andhik Ampuh Yunanto APRIANDY, KEVIN ILHAM Ardhani, Misbahul Arna Fariza Assodiky, Hilmy Aziz, Adam Shidqul Bagas Dewangkara Bima Sena Bayu Dewantara Binti Kholifah Dadet Pramadihanto Daisy Rahmania Syarif Darmawan, Zakha Maisat Eka Desy Intan Permatasari, Desy Intan Deyana Kusuma Wardani Dian Neipa Purnamasari Dimas Bagus Santoso Dona Wahyudi Dzulfiqar, Achmad Fakhri Edelani, Renovita Edi Satriyanto Entin Martiana Kusumaningtyas Fahrudin, Tresna Maulana Fakhri, Haidar Fathoni, Kholid Fauzy, Aryazaky Iman Ferry Astika S Ferry Astika Saputra Ferry Astika Saputra Fitri Setyorini Gary Wills Gunawan, Agus Indra Hamida, Silfiana Nur Hardiyanti, Fitriani Rohmah Hasan Basri Hidayah, Amalia Wirdatul Hidayah, Nadila Wirdatul Hilmy Assodiky Hisyam, Masfu Huda, Achmad Thorikul Idris Winarno Irsal Shabirin Khoirunnisa, Asy Syaffa Kholifah, Binti Kindarya, Fabyan Kusuma, Selvia Ferdiana M Udin Harun Al Rasyid, M Udin Harun Mahardhika, Yesta Medya Masfu Hisyam Maulana, Yufri Isnaini Rochmat Mayangsari, Mustika Kurnia Mufid, Mohammad Robihul Muhammad Fajrul Falah Muhlis Tahir Nadila Wirdatul Hidayah Nana Ramadijanti, Nana Ningrum, Ayu Ahadi Nur Rosyid Mubtadai, Nur Rosyid Nur Sakinah Nur Ulima Rusmayani Prasetyo Primajaya, Grezio Arifiyan Rabiatul Adawiyah Rachmawati, Oktavia Citra Resmi Reesa Akbar Rengga Asmara Rengga Asmara Riyanto Sigit, Riyanto Rizky Yuniar Hakkun Rosmaliati, Rosmaliati Rozie, Fachrul Rudi Kurniawan Rulisiana Widodo S, Ferry Astika Sa'adah, Umi Sesulihatien, Wahjoe Tjatur Setiawardhana, Setiawardhana Sritrusta Sukaridhoto Sudaryanto, Aris Sumarsono, Irwan Susanti, Puspasari Tessy Badriyah, Tessy Tresna Maulana Fahrudin Tri Harsono Ubed, Imanullah Ali Utomo, Agus Priyo Walujo, Ivana Yudith Wibowo, Prasetyo Willy Sandhika Yufri Isnaini Rochmat Maulana