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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 Achmad Thorikul Huda Adam Ghazy Al Falah Adam Prugel-Bennett Agung Muliawan Ahmad Syauqi Ahsan Ahsan, Ahmad Syauqi Aidil Saputra Kirsan 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 Assodiky, Hilmy Asy Syaffa Khoirunnisa Ayu Ahadi Ningrum 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 Permatasari, Desy Intan Deyana Kusuma Wardani Dian Neipa Purnamasari Dimas Bagus Santoso Dona Wahyudi Dzulfiqar, Achmad Fakhri Edelani, Renovita Edi Satriyanto Entin Martiana Kusumaningtyas Fachrul Rozie Fahrudin, Tresna Maulana Fahrudin, Tresna Maulana Fakhri, Haidar Fathoni, Kholid Fauzy, Aryazaky Iman Ferry Astika Saputra Ferry Astika Saputra Ferry Astika Saputra Fitri Setyorini Gary Wills Grezio Arifiyan Primajaya Gunawan, Agus Indra Hardiyanti, Fitriani Rohmah Hasan Basri Hidayah, Amalia Wirdatul Hidayah, Nadila Wirdatul Hisyam, Masfu Hisyam, Masfu Idris Winarno Izza Nur Afifah Khoirunnisa, Asy Syaffa Kholifah, Binti Kindarya, Fabyan Kusuma, Harun Indra Kusuma, Selvia Ferdiana M Udin Harun Al Rasyid, M Udin Harun Mahardhika, Yesta Medya Maulana, Yufri Isnaini Rochmat Maulana, Yufri Isnaini Rochmat Mayangsari, Mustika Kurnia Mufid, Mohammad Robihul Mufid, Mohammad Robihul Muhammad Fajrul Falah Muhlis Tahir Nadila Wirdatul Hidayah Nana Ramadijanti Nana Ramadijanti, Nana Novie Ayub Windarko Nur Rosyid Mubtadai Nur Rosyid Mubtadai, Nur Rosyid Nur Sakinah Nur Ulima Rusmayani Oktavia Citra Resmi Rachmawati Osamah Abdullah Yahya Amran Prasetyo Primajaya, Grezio Arifiyan Puspasari Susanti Rabiatul Adawiyah Reesa Akbar Rengga Asmara Rengga Asmara Renovita Edelani Riyanto Sigit, Riyanto Rizky Yuniar Hakkun Rosmaliati, Rosmaliati Rudi Kurniawan Rudi Kurniawan Rulisiana Widodo S, Ferry Astika S, Ferry Astika Sa'adah, Umi Selvia Ferdiana Kusuma Setiawardhana Setiawardhana Setiawardhana, Setiawardhana Shabirin, Irsal Silfiana Nur Hamida Sritrusta Sukaridhoto Sudaryanto, Aris Sumarsono, Irwan Tahir, Muhlis Tessy Badriyah, Tessy Tri Harsono Ubed, Imanullah Ali Umi Sa'adah Utomo, Agus Priyo Wahjoe Tjatur Sesulihatien Walujo, Ivana Yudith Wibowo, Prasetyo Willy Sandhika