The US Healthcare Fraud Detection market studied was valued at USD 337.41 million in 2018, and is expected to reach USD 1254.48 million by 2024, with an anticipated CAGR of 24.47%, during the forecast period (2019-2024).
The major factors attributing to the growth of the US healthcare fraud detection market are increasing fraudulent activities in the US healthcare, growing pressure to increase in operations efficiency and reduce healthcare spending, and prepayment review model.
For instance, as per the National Health Care Anti-Fraud Association stated that health insurance frauds in the United States cost around USD 80 billion per year to the consumers. Criminals are looking forward to profit from the people across the country. As most of the people in the country are having health insurance, free medical treatments or complimentary consultation offers are being stolen.
Such cases of frauds in health insurance are causing damages to the medical history of people. A few years back, it was difficult for the healthcare providers to identify the fraud, as criminals were playing with all types of patient identifications and insurance information. Due to such frauds, patients are compelled to pay higher premiums and their medical history is compromised. Therefore, the US healthcare department is currently more focused on the reduction of such cases by implementing fraud detection technology. Therefore, it is believed that due to the rising fraudulent activities in the US healthcare department, the market studied may grow in the future.
Scope of the Report
The term healthcare fraud detection refers to solutions that are helpful in earlier detection of errors in claim submissions, duplication of claims, etc., to minimize healthcare spending and improve efficiency.
Key Market Trends
In the Application Segment, the review of Insurance Claims is Expected to Hold the Major Share and Expected to do Same
The healthcare fraud detection solution plays 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. Health insurance fraud is a type of fraud in which false or misleading information is provided to a health insurance company in an attempt to have them pay unauthorized benefits to the policy holderâ another partyâ or the entity providing services. The offense can be committed by the insured individual or the provider of health services.
Most health insurances include specific benefitsâ and health insurance fraud practices, such as overbilling for the type of services received, rob consumers of these benefits. A central objective of the recent US healthcare policy reform, most notably the Affordable Care ActŐs (ACA) Health Insurance Marketplace, has been to increase access to stable, affordable health insurance. Owing to the aforementioned factors, the review of insurance claims segment is expected to grow exponentially in the US healthcare fraud detection market.
The healthcare fraud detection market is moderately competitive and consists of several major players. In terms of market share, few of the major players currently dominate the market. With the rising adoption of Healthcare IT and the increasing number of fraud cases, few other smaller players are expected to enter into the market in the coming years. Some of the major players of the market are Conduent Inc., DXC Technology Company, EXL (Scio Health Analytics), International Business Machines Corporation (IBM), and Mckesson are among others.
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1.1 Study Deliverables
1.2 Study Assumptions
1.3 Scope of the Study
2 RESEARCH METHODOLOGY
3 EXECUTIVE SUMMARY
4 MARKET DYNAMICS
4.1 Market Overview
4.2 Market Drivers
4.2.1 Increasing Fraudulent Activities in the US Healthcare
4.2.2 Growing Pressure to Increase in Operations Efficiency and Reduce Healthcare Spending
4.2.3 Prepayment Review Model
4.3 Market Restraints
4.3.1 Lack of Skilled Healthcare IT Labors in the Country
4.4 Porter's Five Force Analysis
4.4.1 Threat of New Entrants
4.4.2 Bargaining Power of Buyers/Consumers
4.4.3 Bargaining Power of Suppliers
4.4.4 Threat of Substitute Products
4.4.5 Intensity of Competitive Rivalry
5 MARKET SEGMENTATION
5.1 By Type
5.1.1 Descriptive Analytics
5.1.2 Predictive Analytics
5.1.3 Prescriptive Analytics
5.2 By Application
5.2.1 Review of Insurance Claims
5.2.2 Payment Integrity
5.3 By End User
5.3.1 Private Insurance Payers
5.3.2 Government Agencies
5.3.3 Other End Users
6 COMPETITIVE LANDSCAPE
6.1 Company Profiles
6.1.1 Conduent Inc.
6.1.2 DXC Technology Company
6.1.3 EXL (Scio Health Analytics)
6.1.4 International Business Machines Corporation (IBM)
6.1.6 Northrop Grumman
6.1.7 OSP Labs
6.1.8 SAS Institute
6.1.9 Relx Group PLC (LexisNexis)
6.1.10 United Health Group Incorporated (Optum Inc.)
7 MARKET OPPORTUNITIES AND FUTURE TRENDS
Secondary Research Information is collected from a number of publicly available as well as paid databases. Public sources involve publications by different associations and governments, annual reports and statements of companies, white papers and research publications by recognized industry experts and renowned academia etc. Paid data sources include third party authentic industry databases.
Once data collection is done through secondary research, primary interviews are conducted with different stakeholders across the value chain like manufacturers, distributors, ingredient/input suppliers, end customers and other key opinion leaders of the industry. Primary research is used both to validate the data points obtained from secondary research and to fill in the data gaps after secondary research.
The market engineering phase involves analyzing the data collected, market breakdown and forecasting. Macroeconomic indicators and bottom-up and top-down approaches are used to arrive at a complete set of data points that give way to valuable qualitative and quantitative insights. Each data point is verified by the process of data triangulation to validate the numbers and arrive at close estimates.
The market engineered data is verified and validated by a number of experts, both in-house and external.
REPORT WRITING/ PRESENTATION
After the data is curated by the mentioned highly sophisticated process, the analysts begin to write the report. Garnering insights from data and forecasts, insights are drawn to visualize the entire ecosystem in a single report.