The Global Healthcare Fraud Analytics Market size is expected to reach $6.6 Billion by 2028, rising at a market growth of 23.0% CAGR during the forecast period.
Health-care fraud is characterized as illegal deception aimed at gaining financial benefit in the areas of medication manufacture, product quality, medical practice, and healthcare insurance. The practice of healthcare fraud includes cheating government-sponsored healthcare schemes, as well as defrauding insurance companies, businesses, and consumers. Leading life sciences companies are currently using a variety of data mining techniques to combat these fraudulent operations. These data mining techniques entail scouring databases for new information, such as healthcare insurance data, fraud strategies, and healthcare information systems, among other things.
In the coming years, the healthcare fraud detection market is expected to be driven by a rise in the number of fraudulent events in health care, an uptick in the frequency of patients going to opt for health care insurance, and an increase in the pressure to keep a record of fraud and abuse in health care spending. Other factors include a growth in the frequency of health care BPO and fraud identity management software, quick acceptance of cloud-based analytical solutions, increased influence of social media on the health care industry, and the efficiency of artificial intelligence in healthcare services & solutions.
With a unique visualization interface that allows users to go over individual and account views to evaluate all relevant activities and relationships at a network dimension, users may discover linkages within apparently unrelated claims. With social network diagrams and extensive data mining skills, organizations may gain an improved understanding of new dangers and prevent large losses before they happen. Additionally, by constantly developing models and modifying the system, organizations can keep in front of variations in payment and cost-cutting trends.
The healthcare fraud analytics industry is confronted with numerous obstacles. Business dynamics are being impacted by travel restrictions and quarantines, shuts down in outdoor/indoor activities, temporary business outages, supply-demand fluctuations, stock market volatility, diminishing business confidence, and a myriad of other worries. In the healthcare industry, doctors, patients, physicians, and other medical experts have all been engaged in fraud situations. Many healthcare professionals and experts have been discovered scamming patients for monetary gain. Patients' fraudulent acts in the healthcare sector include fraudulently obtaining sickness certificates, prescription fraud, and evasion of medical payments.
The number of people who have benefited from various healthcare initiatives has increased dramatically over time. The increase in the ageing population, growth in healthcare costs, and rising illness load are all factors leading to the expansion of the health insurance market. The number of people without health insurance in the United States has declined dramatically, from the year 2010 to the year 2016. During the 2017 open enrollment period, multiple millions of people signed up for or renewed their health insurance, as per National Center for Health Statistics.
The healthcare business is evolving at a breakneck pace, and one of the primary factors driving this evolution is the increasing influence of healthcare communication via social media. Not only has social media grown in popularity as a source of health information, but it also allows for dual-way public communication among patients, other third parties, and providers. This contributes to the creation of a big forum for comprehensive health discussions.
The execution of fraud analytics solutions consumes a huge time. Developing new databases, user interfaces, and predictive models; assessing and implementing models; and tracking their efficacy are all part of the process. During this step, data analysts execute algorithms till they find the best accurate forecasting model. The eave-droppers are very clever to notice that which organization is lacking regular upgrades & updates and is the deployment process time-consuming and accordingly plan & execute the unauthorized interference.
Based on delivery model, the healthcare fraud analytics market is bifurcated into On-premises and Cloud-based. The On-premises segment acquired the highest revenue share in the healthcare fraud analytics market in 2021. The simplicity of access to data being on-site, i.e., hospitals, etc., results in better record management and data monitoring, among other things. Current systems in small businesses are functional, but when scaled up, data management can become complicated and cumbersome, especially if the company is dealing with a large data set. This could imply a significant financial investment in data storage and security.
Based on Application, the healthcare fraud analytics market is divided into Insurance Claim Review, Pharmacy billing Issues, Payment Integrity, and Others. The pharmacy billing issue segment garnered a significant revenue share in the healthcare fraud analytics market in 2021. The increased frequency of medical billing fraud is happening in pharmacies. The objective of pharmacy billing is to reduce expenses from the admin side.
Based on end-use, the healthcare fraud analytics market is classified into Public & Government Agencies, Private Insurance Payers, Third-party Service Providers, and Employers. The Public & Government Agencies segment acquired the highest revenue share in the healthcare fraud analytics market in 2021. A greater amount of patients in government hospitals, as well as the increased vulnerability of government organizations to fraudulent operations because of a lack of technologically updated infrastructure, specifically in developing countries, are two significant factors leading to the big percentage.
Based on solution type, the healthcare fraud analytics market is segmented into Descriptive Analytics, Prescriptive Analytics, and Predictive Analytics. The descriptive analytics segment acquired the highest revenue share in the healthcare fraud analytics market in 2021. For the purpose of identifying patterns and linkages, it uses both current and historical data. This aids in the more accurate detection of potential scams. It also serves as a foundation for implementing predictive and prescriptive analytics effectively. This contributes to the segment's continued expansion.
Based on Region, the healthcare fraud analytics market is analyzed across North America, Europe, Asia Pacific, and LAMEA. North America emerged as the leading region in the healthcare fraud analytics market with the largest revenue share in 2021. This is due to rising healthcare spending, increased adoption of healthcare IT, and an increase in the number of fraud instances. As per the National Health Care Anti-Fraud Association, the United States spends several trillions on health care each year (NHCAA). NHCAA believes that health care fraud costs tens of billions of dollars out of that total. There is the availability of various advanced solutions and services associated with healthcare fraud detection, as well as strategic steps taken by big players present in the country.
The leading players in the market are competing with diverse innovative offerings to remain competitive in the market. The below illustration shows the percentage of revenue shared by some of the leading companies in the market. The leading players of the market are adopting various strategies in order to cater demand coming from the different industries. The key developmental strategies in the market are Acquisitions, and Partnerships & Collaborations.
The market research report covers the analysis of key stake holders of the market. Key companies profiled in the report include Wipro Limited, IBM Corporation, DXC Technology Company, SAS Institute, Inc., Conduent, Incorporated, HCL Technologies Ltd., UnitedHealth Group, Inc. (Optum, Inc.), OSP Labs, Cotiviti, Inc., and ExlService Holdings, Inc.
Health-care fraud is characterized as illegal deception aimed at gaining financial benefit in the areas of medication manufacture, product quality, medical practice, and healthcare insurance. The practice of healthcare fraud includes cheating government-sponsored healthcare schemes, as well as defrauding insurance companies, businesses, and consumers. Leading life sciences companies are currently using a variety of data mining techniques to combat these fraudulent operations. These data mining techniques entail scouring databases for new information, such as healthcare insurance data, fraud strategies, and healthcare information systems, among other things.
In the coming years, the healthcare fraud detection market is expected to be driven by a rise in the number of fraudulent events in health care, an uptick in the frequency of patients going to opt for health care insurance, and an increase in the pressure to keep a record of fraud and abuse in health care spending. Other factors include a growth in the frequency of health care BPO and fraud identity management software, quick acceptance of cloud-based analytical solutions, increased influence of social media on the health care industry, and the efficiency of artificial intelligence in healthcare services & solutions.
With a unique visualization interface that allows users to go over individual and account views to evaluate all relevant activities and relationships at a network dimension, users may discover linkages within apparently unrelated claims. With social network diagrams and extensive data mining skills, organizations may gain an improved understanding of new dangers and prevent large losses before they happen. Additionally, by constantly developing models and modifying the system, organizations can keep in front of variations in payment and cost-cutting trends.
COVID-19 Impact Analysis
The healthcare fraud analytics industry is confronted with numerous obstacles. Business dynamics are being impacted by travel restrictions and quarantines, shuts down in outdoor/indoor activities, temporary business outages, supply-demand fluctuations, stock market volatility, diminishing business confidence, and a myriad of other worries. In the healthcare industry, doctors, patients, physicians, and other medical experts have all been engaged in fraud situations. Many healthcare professionals and experts have been discovered scamming patients for monetary gain. Patients' fraudulent acts in the healthcare sector include fraudulently obtaining sickness certificates, prescription fraud, and evasion of medical payments.
Market Growth Factors
Growth In Frequency Of People Looking For Health Insurance
The number of people who have benefited from various healthcare initiatives has increased dramatically over time. The increase in the ageing population, growth in healthcare costs, and rising illness load are all factors leading to the expansion of the health insurance market. The number of people without health insurance in the United States has declined dramatically, from the year 2010 to the year 2016. During the 2017 open enrollment period, multiple millions of people signed up for or renewed their health insurance, as per National Center for Health Statistics.
Social Media's Emergence And Influence On The Healthcare Business
The healthcare business is evolving at a breakneck pace, and one of the primary factors driving this evolution is the increasing influence of healthcare communication via social media. Not only has social media grown in popularity as a source of health information, but it also allows for dual-way public communication among patients, other third parties, and providers. This contributes to the creation of a big forum for comprehensive health discussions.
Market Restraining Factors
Time-Consuming Deployment And The Need For Frequent Upgrades
The execution of fraud analytics solutions consumes a huge time. Developing new databases, user interfaces, and predictive models; assessing and implementing models; and tracking their efficacy are all part of the process. During this step, data analysts execute algorithms till they find the best accurate forecasting model. The eave-droppers are very clever to notice that which organization is lacking regular upgrades & updates and is the deployment process time-consuming and accordingly plan & execute the unauthorized interference.
Delivery Model Outlook
Based on delivery model, the healthcare fraud analytics market is bifurcated into On-premises and Cloud-based. The On-premises segment acquired the highest revenue share in the healthcare fraud analytics market in 2021. The simplicity of access to data being on-site, i.e., hospitals, etc., results in better record management and data monitoring, among other things. Current systems in small businesses are functional, but when scaled up, data management can become complicated and cumbersome, especially if the company is dealing with a large data set. This could imply a significant financial investment in data storage and security.
Application Outlook
Based on Application, the healthcare fraud analytics market is divided into Insurance Claim Review, Pharmacy billing Issues, Payment Integrity, and Others. The pharmacy billing issue segment garnered a significant revenue share in the healthcare fraud analytics market in 2021. The increased frequency of medical billing fraud is happening in pharmacies. The objective of pharmacy billing is to reduce expenses from the admin side.
End- Use Outlook
Based on end-use, the healthcare fraud analytics market is classified into Public & Government Agencies, Private Insurance Payers, Third-party Service Providers, and Employers. The Public & Government Agencies segment acquired the highest revenue share in the healthcare fraud analytics market in 2021. A greater amount of patients in government hospitals, as well as the increased vulnerability of government organizations to fraudulent operations because of a lack of technologically updated infrastructure, specifically in developing countries, are two significant factors leading to the big percentage.
Solution type Outlook
Based on solution type, the healthcare fraud analytics market is segmented into Descriptive Analytics, Prescriptive Analytics, and Predictive Analytics. The descriptive analytics segment acquired the highest revenue share in the healthcare fraud analytics market in 2021. For the purpose of identifying patterns and linkages, it uses both current and historical data. This aids in the more accurate detection of potential scams. It also serves as a foundation for implementing predictive and prescriptive analytics effectively. This contributes to the segment's continued expansion.
Regional Outlook
Based on Region, the healthcare fraud analytics market is analyzed across North America, Europe, Asia Pacific, and LAMEA. North America emerged as the leading region in the healthcare fraud analytics market with the largest revenue share in 2021. This is due to rising healthcare spending, increased adoption of healthcare IT, and an increase in the number of fraud instances. As per the National Health Care Anti-Fraud Association, the United States spends several trillions on health care each year (NHCAA). NHCAA believes that health care fraud costs tens of billions of dollars out of that total. There is the availability of various advanced solutions and services associated with healthcare fraud detection, as well as strategic steps taken by big players present in the country.
The leading players in the market are competing with diverse innovative offerings to remain competitive in the market. The below illustration shows the percentage of revenue shared by some of the leading companies in the market. The leading players of the market are adopting various strategies in order to cater demand coming from the different industries. The key developmental strategies in the market are Acquisitions, and Partnerships & Collaborations.
The market research report covers the analysis of key stake holders of the market. Key companies profiled in the report include Wipro Limited, IBM Corporation, DXC Technology Company, SAS Institute, Inc., Conduent, Incorporated, HCL Technologies Ltd., UnitedHealth Group, Inc. (Optum, Inc.), OSP Labs, Cotiviti, Inc., and ExlService Holdings, Inc.
- Oct-2021: ExlService Holding joined hands with GEOX, a leader in supplying geospatial data to insurers. This collaboration aimed to provide unified image analytics offering to insurance carriers. Further, this partnership aimed to improve assist carriers in attaining enhanced underwriting assessment, smart roof condition assessment, more accurate property renewal assessment, and improved claim processing assistance.
- Apr-2021: Wipro entered into an agreement to acquire Ampion, an Australia-located provider of cyber security, quality engineering services, and DevOps. This acquisition aimed to bring scale and market flexibility and speed to respond to the increasing demands of customers.
- Feb-2021: IBM Corporation came into partnership with Watson Health and Humana, a not-for-profit American health insurance company located in Louisville, Kentucky. This partnership aimed to aid deliver an improved member experience while giving higher transparency and clarity on advantages and other associated matters for Humana Employer Group members.
- Sep-2020: HCL Technologies extended its partnership with Google Cloud. This partnership aimed for customers to have real-time valuable information from the operational data at a significantly lower total cost of ownership. Further, this partnership aimed to bring HCL'S Actian portfolio, beginning with Actian Avalanche, to Google Cloud. Action Avalanche is a high-performance hybrid cloud data warehouse created to support enterprises highly demanding operational analytics workloads.
- Jul-2020: SAS Institute formed a partnership with National Health Authority (NHA), NHA is responsible for implementing India’s flagship public health insurance/assurance scheme Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. This partnership aimed to aid check abuse and fraud in the execution structure of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojna (AB PM-JAY) scheme. In addition, SAS is expected to deliver an end-to-end framework to ensure claim processing with notable elements for alert management, fraud detection, and case-handling for NHA.
- Jun-2020: SAS Institute came into a partnership with Microsoft Corporation. This partnership aimed to allow customers to simply run the SAS workload in the cloud, expanding the business solutions and unlocking vital value from the digital transformation initiatives. Under this partnership, the companies is expected to aid the customers to fasten their growth and discover new methods to boost innovation with a wide set of SAS Analytics offerings on Microsoft Azure.
- Jun-2018: Wipro came into a partnership with Opera Solutions, a global leader in applied Big Data analytics and artificial intelligence (AI). This partnership aimed to integrate Opera Solutions’ powerful AI and machine learning based Fraud, Waste, and Abuse (FWA) detection engine with Wipro’s extensive full-service claim processing capabilities in claims review, which comprises the forensic examination of questionable audits, claims, negotiations, adjustments recovery follow-up and payment posting. Further, this partnership aimed to solve the concerns of waste, fraud, and abuse in healthcare insurance claims in the United States.
Scope of the Study
Market Segments Covered in the Report:
By Delivery Model
- On-premise
- Cloud
By Application
- Insurance Claim Review
- Pharmacy billing Issue
- Payment Integrity
- Others
By End User
- Public & Government Agencies
- Private Insurance Payers
- Third-party Service Providers
- Employers
By Solution Type
- Descriptive Analytics
- Predictive Analytics
- Prescriptive Analytics
By Geography
- North America
- US
- Canada
- Mexico
- Rest of North America
- Europe
- Germany
- UK
- France
- Russia
- Spain
- Italy
- Rest of Europe
- Asia Pacific
- China
- Japan
- India
- South Korea
- Singapore
- Malaysia
- Rest of Asia Pacific
- LAMEA
- Brazil
- Argentina
- UAE
- Saudi Arabia
- South Africa
- Nigeria
- Rest of LAMEA
Key Market Players
List of Companies Profiled in the Report:
- Wipro Limited
- IBM Corporation
- DXC Technology Company
- SAS Institute, Inc.
- Conduent, Incorporated
- HCL Technologies Ltd.
- UnitedHealth Group, Inc. (Optum, Inc.)
- OSP Labs
- Cotiviti, Inc.
- ExlService Holdings, Inc.
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Table of Contents
Chapter 1. Market Scope & Methodology
Chapter 2. Market Overview
Chapter 3. Competition Analysis - Global
Chapter 4. Global Healthcare Fraud Analytics Market by Delivery Model
Chapter 5. Global Healthcare Fraud Analytics Market by Application
Chapter 6. Global Healthcare Fraud Analytics Market by End User
Chapter 7. Global Healthcare Fraud Analytics Market by Solution Type
Chapter 8. Global Healthcare Fraud Analytics Market by Region
Chapter 9. Company Profiles
Companies Mentioned
- Wipro Limited
- IBM Corporation
- DXC Technology Company
- SAS Institute, Inc.
- Conduent, Incorporated
- HCL Technologies Ltd.
- UnitedHealth Group, Inc. (Optum, Inc.)
- OSP Labs
- Cotiviti, Inc.
- ExlService Holdings, Inc.
Methodology
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Table Information
| Report Attribute | Details |
|---|---|
| No. of Pages | 269 |
| Published | May 2022 |
| Forecast Period | 2021 - 2028 |
| Estimated Market Value ( USD | $ 1590 Million |
| Forecasted Market Value ( USD | $ 6607 Million |
| Compound Annual Growth Rate | 23.0% |
| Regions Covered | Global |
| No. of Companies Mentioned | 10 |
