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

  • ID: 4622447
  • Report
  • July 2019
  • Region: Global
  • 113 pages
  • Mordor Intelligence


  • CGI Inc.
  • DXC Technology Company
  • Mckesson
  • Northrop Grumman
  • OSP Labs
  • SAS Institute
  • MORE
Market Overview

The Global Healthcare Fraud Detection market studied was valued at USD 679.18 million in 2018, and is expected to reach USD 2540.29 million by 2024, with an anticipated CAGR of 24.59%, during the forecast period (2019-2024).

The major factors attributing to the growth of the healthcare fraud detection market are rising healthcare expenditure, rise in the number of patients opting for health insurance, growing pressure to increase operations efficiency and reduce healthcare spending, and increasing fraudulent activities in healthcare. The healthcare industry is witnessing a number of cases of frauds, which can be done by patients, doctors, physicians, and other medical specialists. Many healthcare providers and specialists are caught doing the frauds, for the sake of profit.

Fraudulent cases in healthcare that are done by patients include fraudulent provision of sickness certificates, prescription fraud, and evasion of medical charges. Medical professionals are also involved in the frauds, which contain prescription fraud by pharmacists, fraud and error concerning payments for medical tests, facility services, and consultations.

And even the healthcare expenditure is rising for instance currently, low and middle-income countries across the world are witnessing growth in healthcare expenditure. As per the 2016 report, the World Health Organization stated that this growth is approximately 6% per annum, as compared to 4% in high-income countries.

A report from WHO on global healthcare expenditure (2016) states that governments spend USD 60 per person on health, in lower-middle-income countries, and around USD 270 per person in upper-middle-income countries. For the upper-income countries, healthcare expenditure is equally distributed, which reflects 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 of the governments toward health spending in these countries. Most of the insurance companies are adopting fraud detection software, 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.

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 the 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. In healthcare insurance fraud, the 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, enabling loss control units to achieve higher coverage with low false-positive rates. Moreover, the quality and quantity of available data have a huge impact on predictive accuracy than the quality of the algorithm. There are various organizations across the world that aims to reduce the healthcare insurance fraud, such as Insurance Fraud Bureau of Australia (IFBA), Canadian Life and Health Insurance Association (CLHIA), NHS Counter Fraud Authority (NHSCFA), and European Healthcare Fraud & Corruption Network (EHFCN), among others. Presence of such type of organizations is expected to create more awareness among the users, thereby leading to high demand for healthcare fraud detection solutions.

North America Dominates the Market and Expected to do 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, increasing healthcare IT adoption, a growing number of fraud cases. In the North America region, the United States holds the largest market share. The Middle East & African region is anticipated to have the lowest market size, in the coming future. In terms of growth rate, Asia-Pacific is expected to be the fastest-growing region.

Competitive Landscape

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 CGI Inc., DXC Technology Company, EXL (Scio Health Analytics), International Business Machines Corporation (IBM), and Mckesson are among others.
Note: Product cover images may vary from those shown


  • CGI Inc.
  • DXC Technology Company
  • Mckesson
  • Northrop Grumman
  • OSP Labs
  • SAS Institute
  • MORE
1.1 Study Deliverables
1.2 Study Assumptions
1.3 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 Operations 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 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

5.1 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
5.4 Geography
5.4.1 North America US Canada Mexico
5.4.2 Europe Germany UK 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 EXL (Scio Health Analytics)
6.1.4 International Business Machines Corporation (IBM)
6.1.5 Mckesson
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.)

Note: Product cover images may vary from those shown


  • CGI Inc.
  • DXC Technology Company
  • EXL (Scio Health Analytics)
  • International Business Machines Corporation (IBM)
  • Mckesson
  • Northrop Grumman
  • OSP Labs
  • SAS Institute
  • Relx Group PLC (LexisNexis)
  • United Health Group Incorporated (Optum Inc.)
Note: Product cover images may vary from those shown