Healthcare Fraud Analytics Market

Global Healthcare Fraud Analytics Size (2023 to 2028)

The global healthcare fraud analytics market is expected to be worth USD 12.7 billion by 2028 from USD 3.24 billion in 2023, growing at a CAGR of 31.38% from 2023 to 2028.

Healthcare fraud is a type of white-collar crime that involves filing false healthcare claims to make money. Organized crime groups and a small fraction of fraudulent healthcare practitioners commit the vast bulk of healthcare fraud. Billing for more expensive services or procedures, misrepresenting non-covered treatments, insurance scams, and other sorts of healthcare fraud are among the most common. Healthcare fraud analytics refers to fraud detection solutions and software that aid in detecting healthcare frauds such as claim submission errors, claim duplication, pharmacist prescription fraud, and health insurance fraud.

Impact of COVID-19 on the global healthcare fraud analytics market:

The worldwide healthcare fraud analytics market is confronted with numerous obstacles. Travel bans and quarantines halts in indoor/outdoor activities, temporary business shutdowns, supply-demand changes, stock market volatility, dwindling business confidence, and a slew of other uncertainties are all having an impact on business dynamics. Patients, doctors, physicians, and other medical specialists have all been involved in fraud situations in the healthcare industry. Many healthcare professionals and specialists have been discovered scamming patients for financial gain. Patient fraud in the healthcare industry includes fraudulently obtaining health certifications, prescription fraud, and avoiding medical payments. However, with fewer procedures being performed and equipment purchases being delayed or postponed, revenues in the medical technology and imaging industry are dropping. As a result, the market for healthcare fraud analytics has had negative growth during the pandemic.

MARKET DRIVERS:

Many fraudulent actions in healthcare, strong returns on investment, the growing geriatric population, the incidence of chronic and lifestyle conditions, and an increase in the number of pharmacy claims-related scams are all contributing to market expansion. Customer preferences are changing, investments in healthcare infrastructure are expanding, and patient demographics are changing, all of which are driving market expansion. Furthermore, increased government spending on the healthcare ecosystem to combat fraud is likely to enhance the global market throughout the forecast period.

With the increasing number of occurrences of healthcare fraud in many regions of the world, the necessity for precise detection has become critical, drawing global attention to healthcare fraud analytics solutions. One of the key factors driving the development of healthcare fraud analytics is the significant expansion in the population pool applying for healthcare insurance, which creates further pressure on healthcare service providers to avoid potential fraud and abuse occurrences. Also driving demand for healthcare fraud analytics is the expanding number of healthcare BPOs and fraud identity management software, as well as the impact of social media on the healthcare business.

MARKET RESTRAINTS:

A shortage of skilled workers restricts the market's growth to use the features and fraud analytics, higher deployment costs, particularly for small and medium businesses, and rising data security risks. Concerns about healthcare fraud analytics, on the other hand, are a significant stumbling block to the market's expansion. Furthermore, in the forecast period, the market for healthcare fraud analytics would be challenged by time-consuming implementation and the requirement for frequent modifications.

REPORT COVERAGE:

This research report on the global healthcare fraud analytics market has been segmented and sub-segmented based on product, application, end-user, and region.

Healthcare Fraud Analytics Market – By Product:

• Healthcare Descriptive Analytics
• Healthcare Predictive Analytics
• Healthcare Prescriptive Analytics

The healthcare descriptive analytics segment took the most market share. The increased use of descriptive analytics for examining numerous healthcare decisions and their effects on service performance, clinical outcomes, and results is credited with the segment's growth. Descriptive analytics uses data visualization to uncover treatment patterns or to aid in answering specific queries, resulting in a holistic view of evidence-based clinical practice. Descriptive analytics is the foundation for effective prescriptive or predictive analytics in healthcare. These analytics will now use the fundamentals of descriptive analytics and combine them with new data sources to produce valuable insights.

Healthcare Fraud Analytics Market – By Application:

• Insurance Claims Review
• Pharmacy Billing Misuse
• Payment Integrity

The Insurance Claims Review segment is expected to hold most of the market share. Because most fraud incidents occur when claiming insurance, healthcare fraud detection systems play a critical role in examining insurance claims. False information is submitted to a health insurance company to have them pay illegitimate benefits to the policyholder, another party, or the service provider. Machine learning techniques aid predictive accuracy, allowing loss control devices to gain excellent coverage while reducing false favorable rates. Furthermore, the quality and amount of available data have a much more significant impact on predicted accuracy than the algorithm's quality.

Healthcare Fraud Analytics Market – By End-User:

• Public & Government Agencies
• Private Insurance Payers
• Third-party service providers
• Employers

The public and government agencies segment held the most significant proportion of the healthcare fraud analytics market. In addition, the rising expense of healthcare fraud is posing a financial danger to the public and government institutions around the world. These reasons incentivize payer organizations involved with these agencies to use analytics solutions to reduce losses suffered due to FWA and incorrect payments, fueling the market growth.

Healthcare Fraud Analytics Market – By Region:

• North America
• Europe
• Asia-Pacific
• Latin America
• Middle East and Africa

North America held the highest proportion of the healthcare fraud analytics market geographically. Many people with health insurance, growing healthcare fraud, favorable government anti-fraud initiatives, pressure to reduce healthcare costs, technological advancements, and greater product and service availability in this region are all factors that contribute to the region's high market share. Furthermore, North America is home to the most important companies in the healthcare fraud analytics market.

Due to expanding spending on healthcare analytical services, rising prepayment review models, improving returns on investment, and growth in pharmacy claims-related fraud in this area, Asia-Pacific is expected to dominate the healthcare fraud analytics market.

Due to the increasing integration of artificial intelligence in various healthcare products and services in this region, Europe is predicted to be the fastest-growing healthcare fraud analytics market.

KEY MARKET PARTICIPANTS:

Conduent Inc., DXC Technology, Scioinspire, Corp., Optum, Inc., SAS Institute, Pondera Solutions, LexisNexis Risk Solutions, Fair, Isaac, and Company (FICO), Cotiviti, Inc., and Whitehatai are some of the prominent companies operating in the global healthcare fraud analytics market profiled in this report.

RECENT HAPPENINGS IN THIS MARKET:

• LexisNexis Risk Solutions and QuadraMed, a division of Harris Healthcare, worked in 2019 to improve patient matching for QuadraMed's Enterprise Master Patient Index (EMPI) software and clean-up customers at over 1,200 healthcare facilities.
• Verscend Technologies, Inc., a portfolio company of Veritas Capital and a leader in data-driven healthcare solutions, acquired Cotiviti Holdings, Inc., a leading provider of payment accuracy and analytics-driven solutions focusing primarily on the healthcare market in 2018.