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All Journal Psyche 165 Journal Medicor : Journal of Health Informatics and Health Policy
Susi Ari Kristina
Universitas Gadjah Mada
Education Health Professions Library & Information Science Nursing Public Health Social Sciences Other

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Data-Driven Approaches to Fraud Detection in Health Insurance Claims: A Systematic Review of Medical and Pharmaceutical Services Sri Rukayah; Susi Ari Kristina
Medicor : Journal of Health Informatics and Health Policy Vol. 4 No. 2 (2026): April 2026
Publisher : Indonesian Scientific Publication

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61978/medicor.v4i2.1352

Abstract

Fraud in health insurance claims continues to impose significant financial and operational burdens on healthcare systems, especially as the volume and complexity of claims increase. Conventional rule-based detection mechanisms, although widely used, have limited adaptability to evolving fraud patterns and high-dimensional data environments. This limitation has driven a shift toward data-driven analytical approaches capable of identifying suspicious patterns more effectively. This systematic review synthesizes peer-reviewed, open-access studies published between 2020 and 2025 that applied rule-based, supervised, unsupervised, or hybrid methods for fraud detection in health insurance claims. A comprehensive search across major databases yielded fourteen eligible studies representing diverse systems, datasets, and methodological designs. The findings indicate a clear transition from traditional rule-based systems to machine learning approaches, particularly in addressing challenges such as label scarcity, class imbalance, and complex fraud patterns. Most studies focused on integrated medical claims, where pharmaceutical fraud was embedded rather than analyzed independently, highlighting a gap in service-specific research. Significant heterogeneity was observed in fraud definitions, preprocessing techniques, labeling strategies, and evaluation metrics, limiting cross-study comparability and emphasizing the need for greater methodological transparency. Across the literature, data-driven approaches are consistently positioned as decision-support tools rather than definitive solutions, reinforcing their role in complementing expert judgment and regulatory oversight. Overall, effective implementation requires context-aware design, reliable labeling, and rigorous real-world validation. Future research should prioritize domain-specific analyses, particularly in pharmaceutical fraud, and improve transparency to support scalable and responsible deployment.
Investigating Perceived Stress and Quality of Life Among Pharmacy Students: A Systematic Review Dhea Ananda Fitri; Susi Ari Kristina; Quang Trung Vo
Psyche 165 Journal Vol. 19 (2026) No. 1
Publisher : Fakultas Psikologi, Universitas Putra Indonesia YPTK Padang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35134/jpsy165.v19i1.678

Abstract

Pharmacy students experience substantial stress due to demanding academic requirements, competitive educational environments, and challenges associated with transitioning into professional roles, which may negatively affect their quality of life. This systematic review aims to examine the relationship between perceived stress and quality of life among pharmacy students and to identify key stress determinants influencing their well-being. Eligible studies focused on pharmacy students, used validated instruments to measure perceived stress and quality of life, and were published between 2020 and 2024. A total of 1,040 records were identified through database searching, of which 12 studies met the inclusion criteria after screening. Two additional studies were identified through manual searching, resulting in 14 studies included in the review. The findings indicate that academic workload, financial pressure, limited social support, and concerns about transitioning into professional practice are the main contributors to perceived stress, which in turn negatively impacts students’ quality of life. Commonly used assessment tools included the Perceived Stress Scale and the Short Form-12 Health Questionnaire. This review highlights the significant impact of perceived stress on the quality of life of pharmacy students and underscores the need for targeted stress management interventions to support their well-being.
Co-Authors Dhea Ananda Fitri Quang Trung Vo Sri Rukayah