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Healthcare Fraud Detection Market - Growth, Trends, COVID-19 Impact, and Forecasts (2022 - 2027)

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  • 113 Pages
  • August 2022
  • Region: Global
  • Mordor Intelligence
  • ID: 4622447
UP TO OFF until Dec 31st 2023
The healthcare fraud detection market was valued at USD 1,313.5 million and is expected to grow at a CAGR of 24.59% during the forecast period. 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 operational efficiency and reduce healthcare spending, and surging fraudulent activities in the healthcare sector, globally.

Since the Covid-19 pandemic started, it has drastically affected the healthcare industry. While some markets in the industry have shown a downfall, some have increased growth, such as the healthcare fraud detection market. The healthcare industry has witnessed several fraud cases done by patients, doctors, physicians, and other medical specialists. It is observed that many healthcare providers and specialists are engaged in fraudulent activities for profit. Many instances prove the increasing number of fraud cases during the pandemic. Justice Department’s False Claims Act Settlements and Judgments exceeded USD 5.6 Billion in 2021, and it was the second-largest amount recoded since 2014 and of the amount settled over USD 5 billion matters related to the health care industry which includes drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians among others. These review processes are helping to detect fraud and improve customer care, additionally boosting the growth of the studied market.

An increasing number of providers are billing and claiming federal health care programs, which are medically unnecessary services or services not rendered as billed. For instance, SavaSeniorCare LLC and its subsidiaries agreed to pay a settlement amount of USD 11.2 million for alleged false claims for rehabilitation therapy services that they provided because of aggressive corporate targets without respecting the patients’ clinical needs. Another instance is that a company called Alere billed and caused others to charge for defective rapid point-of-care testing devices, which were used by Medicare beneficiaries to monitor blood coagulation when taking anticoagulant drugs, and to this, the company paid USD 38.75 million as a settlement as per the source mentioned above. These increasing fraud activities in the healthcare industry is increasing the demand for healthcare fraud detection services and solution, which is positively affecting the growth of the studied market.

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 must pay from their own pockets due to less contribution from the governments toward healthcare expenditure which is resulting in more healthcare fraud, and this is proportionally increasing the healthcare fraud detection market growth.

The adoption of fraud detection software among insurance companies is increasing due to the rising availability of the same in 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.

Key Market Trends

Review of Insurance Claims by Application Segment is Expected to Witness Growth Over the Forecast Period

Healthcare fraud detection solutions play a major role in the review of insurance claims, as most fraud cases occur while claiming insurance. In healthcare insurance fraud, false information is provided to a health insurance company to have them pay unauthorized benefits to the policy holder‚ 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 a huge impact 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 growing interest of the government and private sectors in the review of healthcare insurance claims to save consumers, and nations money is driving the growth of the segment.

In July 2021, a man from Texas was sentenced to more than 11 years in prison for wire fraud and money laundering in connection with the COVID-19 Relief Fraud Scheme obtaining approximately USD 24.8 million. Following the same month, again, a man from California was also arrested and alleged bank fraud, false statements in a loan application, and money laundering raised from the submission of fraudulent applications for Paycheck Protection Program (PPP) funds in the name of Covid-19. There are so many cases are there which were reported and are still counting as sourced from the press releases published by the United States Department of Justice.

Insurance Regulatory and Development Authority of India (IRDAI), annual report 2021, reports that, globally, the share of life insurance business in total premium was 44.50%, and the share of non-life insurance premium was 55.50% in 2020, but India's share of life insurance business was high, and it was at 75.24% while non-life insurances for non-life business accounted of only 24.76%. This increase in the high number of health care life insurance claims has been increasing the demand for the review of the insurance claim segment.

Therefore, the increasing number of insurance claims by the patients/family or companies and others is increasing the demand for the review of the insurance claims segment, and the segment is expected to boost the studied market growth.

North America Dominates the Market and is Expected to Do the Same over 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 the growing number of fraud cases.

The National Health Care Anti-Fraud Association (NHCAA) website Consumer Information section updated in 2021 stated that every year the United States spends over USD 2.27 trillion on health care. NHCAA estimate shows that USD 10 billion are lost to health care fraud, and USD 54 billion is estimated to be scammed and stolen every year in the United States. These activities and loss of wealth in the form of fraud and illegal activities make healthcare fraud the biggest problem in the country. This is expected to drive the healthcare fraud detection market over the forecast period.

Thus, owing to the availability of numerous advanced services and solutions related to healthcare fraud detection and strategic steps taken by major players present in the country, it is expected to drive the growth of the studied market in the North America region over the forecast period.

Competitive Landscape

The market is moderately competitive and consists of several major players. In terms of shares, a few of the major players currently dominate the market. With the rising adoption of healthcare IT and the 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, ExlService Holdings, Inc. (Scio Health Analytics), International Business Machines Corporation (IBM), McKesson Corporation, Northrop Grumman, OSP Labs, SAS Institute Inc., RELX Group plc, UnitedHealth Group. (Optum Inc.) among others.

Additional Benefits:

  • The market estimate (ME) sheet in Excel format
  • 3 months of analyst support

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Table of Contents

1.1 Study Assumptions and Market Definition
1.2 Scope of the Study
4.1 Market Overview
4.2 Market Drivers
4.2.1 Rising Healthcare Expenditure
4.2.2 Rise in the Number of Patients Opting for Health Insurance
4.2.3 Growing Pressure to Increase Operational Efficiency and Reduce Healthcare Spending
4.2.4 Increasing Fraudulent Activities in Healthcare
4.3 Market Restraints
4.3.1 Unwillingness to Adopt Healthcare Fraud Analytics
4.4 Porter's Five Forces 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 (Market Size by Value - USD million)
5.1 Type
5.1.1 Descriptive Analytics
5.1.2 Predictive Analytics
5.1.3 Prescriptive Analytics
5.2 Application
5.2.1 Review of Insurance Claims
5.2.2 Payment Integrity
5.3 End User
5.3.1 Private Insurance Payers
5.3.2 Government Agencies
5.3.3 Other End Users
5.4 Geography
5.4.1 North America United States Canada Mexico
5.4.2 Europe Germany United Kingdom France Italy Spain Rest of Europe
5.4.3 Asia-Pacific China Japan India Australia South Korea Rest of Asia-Pacific
5.4.4 Middle-East and Africa GCC South Africa Rest of Middle-East and Africa
5.4.5 South America Brazil Argentina Rest of South America
6.1 Company Profiles
6.1.1 CGI Inc.
6.1.2 DXC Technology Company
6.1.3 ExlService Holdings, Inc.
6.1.4 International Business Machines Corporation (IBM)
6.1.5 McKesson Corporation
6.1.6 Northrop Grumman
6.1.7 OSP Labs
6.1.8 SAS Institute Inc.
6.1.9 RELX Group plc
6.1.10 UnitedHealth Group. (Optum Inc.)

Companies Mentioned

A selection of companies mentioned in this report includes:

  • CGI Inc.
  • DXC Technology Company
  • ExlService Holdings, Inc.
  • International Business Machines Corporation (IBM)
  • McKesson Corporation
  • Northrop Grumman
  • OSP Labs
  • SAS Institute Inc.
  • RELX Group plc
  • UnitedHealth Group. (Optum Inc.)