Healthcare Fraud Detection Market - Growth, Trends, and Forecast (2019 - 2024)

The Healthcare Fraud Detection Market is segmented by Type, Application (Review of Insurance Claims and Payment Integrity), End User, and Geography.

Market Snapshot

Global Fraud Detection Market_1
Study Period:

2016-2024

Base Year:

2018

Fastest Growing Market:

Asia Pacific

Largest Market:

North America

Key Players:

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Healthcare Fraud Detection Market

The healthcare fraud detection market was valued at USD 679.18 million in 2018, and it is expected to reach USD 2,540.29 million by 2024, registering a CAGR of 24.59%, during the forecast period (2019-2024).

  • The major factors driving the growth of the market are the rising healthcare expenditure, increasing number of patients opting for health insurance, growing pressure to increase the operational efficiency and reduce healthcare spending, and surging fraudulent activities in the healthcare sector, globally.
  •  The healthcare industry has been witnessing a number of cases of frauds, done by patients, doctors, physicians, and other medical specialists. Many healthcare providers and specialists have been observed to be engaged in fraudulent activities, for the sake of profit.
  • In the healthcare sector, fraudulent activities done by patients include the fraudulent procurement of sickness certificates, prescription fraud, and evasion of medical charges.
  • Medical professionals are also involved in fraudulent activities, such as prescription fraud by pharmacists and fraud and errors concerning payments for medical tests, facility services, and consultations.
  • Globally, the healthcare expenditure is rising, especially in the low- and middle-income countries. As per the World Health Organization’s 2016 report, the rise in healthcare expenditure in these countries was approximately 6% per annum, as compared to 4% in the high-income countries.
  • According to the WHO’s report on global healthcare expenditure (2016), the governments in the low- and middle-income countries spend USD 60 per person on healthcare, while those in the upper-middle-income countries spend USD 270.
  • Additionally, in the upper-income countries, healthcare expenditure was observed to be equally distributed, resulting in the overall development of the healthcare system. On the contrary, people in the low- and middle-income countries have to pay from their own pockets, due to less contribution from the governments toward healthcare expenditure.
  • Most of the insurance companies are adopting fraud detection software, due to the rising availability of the same in the developed regions. This growth in the availability of the software is due to the rising healthcare expenditure, which is inspiring the companies to come up with a service or product to meet the market demand.

Scope of the Report

The term ‘healthcare fraud detection’ refers to solutions that are helpful in the early detection of errors in claim submissions, duplication of claims, etc., in order to minimize the healthcare spending and improve the efficiency.

Type
Descriptive Analytics
Predictive Analytics
Prescriptive Analytics
Application
Review of Insurance Claims
Payment Integrity
End User
Private Insurance Payers
Government Agencies
Other End Users
Geography
North America
US
Canada
Mexico
Europe
Germany
UK
France
Italy
Spain
Rest of Europe
Asia-Pacific
China
Japan
India
Australia
South Korea
Rest of Asia-Pacific
Middle East & Africa
GCC
South Africa
Rest of Middle East & Africa
South America
Brazil
Argentina
Rest of South America

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Key Market Trends

By Application, the Review of Insurance Claims Segment is Expected to Hold the Major Share in the Market

Healthcare fraud detection solutions play a major role in the review of insurance claims, as most of the fraud cases occur while claiming the insurance. As per the estimates of the National Health Care Anti-Fraud Association (NHCAA), health care fraud costs the United States around USD 68 billion, annually. In healthcare insurance fraud, false information is provided to a health insurance company, in an attempt to have them pay unauthorized benefits to the policy holder‚ another party‚ or the service provider.

Machine learning techniques help in improving predictive accuracy and enabling loss control units to achieve higher coverage with low false positive rates. Moreover, the quality and quantity of the available data have huge impacts on the predictive accuracy, than the quality of the algorithm. Globally, various organizations, such as the Insurance Fraud Bureau of Australia (IFBA), Canadian Life and Health Insurance Association (CLHIA), NHS Counter Fraud Authority (NHSCFA), and the European Healthcare Fraud & Corruption Network (EHFCN), among others, aim to reduce healthcare insurance fraud. The presence of such organizations is expected to create more awareness among the users, thereby, leading to high demand for healthcare fraud detection solutions.

Healthcare Fraud Detection Market-2

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North America Dominates the Market, and is Expected to Do the Same in the Forecast Period

North America is expected to dominate the overall market, throughout the forecast period. This is due to the increasing healthcare spending, rising healthcare IT adoption, and growing number of fraud cases. In North America, the United States holds the largest market share. Additionally, Middle East & Africa is anticipated to have the lowest market size, during the forecast period. In terms of growth rate, Asia-Pacific is expected to be the fastest growing region.

Healthcare Fraud Detection Market-3

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Competitive Landscape

The market is moderately competitive and consists of several major players. In terms of share, a few of the major players currently dominate the market.  With the rising adoption of healthcare IT and increasing number of fraud cases, a few other smaller players are expected to enter the market in the coming years. Some of the major players in the market are CGI Inc., DXC Technology Company, EXL (Scio Health Analytics), International Business Machines Corporation (IBM), and Mckesson, among others.

Major Players

  1. CGI Inc.
  2. DXC Technology Company
  3. EXL (Scio Health Analytics).
  4. International Business Machines Corporation (IBM)
  5. Mckesson

* Complete list of players covered available in the table of contents below

Healthcare Fraud Detection Market-4

Table of Contents

  1. 1. INTRODUCTION

    1. 1.1 Study Deliverables

    2. 1.2 Study Assumptions

    3. 1.3 Scope of the Study

  2. 2. RESEARCH METHODOLOGY

  3. 3. EXECUTIVE SUMMARY

  4. 4. MARKET DYNAMICS

    1. 4.1 Market Overview

    2. 4.2 Market Drivers

      1. 4.2.1 Rising Healthcare Expenditure

      2. 4.2.2 Rise in the Number of Patients Opting for Health Insurance

      3. 4.2.3 Growing Pressure to Increase Operational Efficiency and Reduce Healthcare Spending

      4. 4.2.4 Increasing Fraudulent Activities in Healthcare

    3. 4.3 Market Restraints

      1. 4.3.1 Unwillingness to Adopt Healthcare Fraud Analytics

    4. 4.4 Porter's Five Forces Analysis

      1. 4.4.1 Threat of New Entrants

      2. 4.4.2 Bargaining Power of Buyers/Consumers

      3. 4.4.3 Bargaining Power of Suppliers

      4. 4.4.4 Threat of Substitute Products

      5. 4.4.5 Intensity of Competitive Rivalry

  5. 5. MARKET SEGMENTATION

    1. 5.1 Type

      1. 5.1.1 Descriptive Analytics

      2. 5.1.2 Predictive Analytics

      3. 5.1.3 Prescriptive Analytics

    2. 5.2 Application

      1. 5.2.1 Review of Insurance Claims

      2. 5.2.2 Payment Integrity

    3. 5.3 End User

      1. 5.3.1 Private Insurance Payers

      2. 5.3.2 Government Agencies

      3. 5.3.3 Other End Users

    4. 5.4 Geography

      1. 5.4.1 North America

        1. 5.4.1.1 US

        2. 5.4.1.2 Canada

        3. 5.4.1.3 Mexico

      2. 5.4.2 Europe

        1. 5.4.2.1 Germany

        2. 5.4.2.2 UK

        3. 5.4.2.3 France

        4. 5.4.2.4 Italy

        5. 5.4.2.5 Spain

        6. 5.4.2.6 Rest of Europe

      3. 5.4.3 Asia-Pacific

        1. 5.4.3.1 China

        2. 5.4.3.2 Japan

        3. 5.4.3.3 India

        4. 5.4.3.4 Australia

        5. 5.4.3.5 South Korea

        6. 5.4.3.6 Rest of Asia-Pacific

      4. 5.4.4 Middle East & Africa

        1. 5.4.4.1 GCC

        2. 5.4.4.2 South Africa

        3. 5.4.4.3 Rest of Middle East & Africa

      5. 5.4.5 South America

        1. 5.4.5.1 Brazil

        2. 5.4.5.2 Argentina

        3. 5.4.5.3 Rest of South America

  6. 6. COMPETITIVE LANDSCAPE

    1. 6.1 Company Profiles

      1. 6.1.1 CGI Inc.

      2. 6.1.2 DXC Technology Company

      3. 6.1.3 EXL (Scio Health Analytics)

      4. 6.1.4 International Business Machines Corporation (IBM)

      5. 6.1.5 Mckesson

      6. 6.1.6 Northrop Grumman

      7. 6.1.7 OSP Labs

      8. 6.1.8 SAS Institute

      9. 6.1.9 Relx Group PLC (LexisNexis)

      10. 6.1.10 United Health Group Incorporated (Optum Inc.)

    2. *List Not Exhaustive
  7. 7. MARKET OPPORTUNITIES AND FUTURE TRENDS

**Competitive Landscape Covers - Business Overview, Financials, Products and Strategies, and Recent Developments

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