The Healthcare Fraud Analytics Market Size was valued at USD 2.42 billion in 2023, and expected to reach USD 14.01 billion by 2031, and grow at a CAGR of 24.5% over the forecast period 2024-2031.
Fraud is known as illegal activity by an organization that results in the violation of regulation in order to obtain higher profits. Fraud has become a common word in many industries while in health care it involves illegal fraud or crime committed in the production of drugs, product quality, treatment, and the pursuit of health insurance.
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Fraud of medical bills, misuse of medical records to increase medical compensation, inaccurate diagnostic reporting are some of the most common frauds occurring in the health care sector. These scams are not trackable and are often unreported resulting in high financial losses to insurance companies and healthcare companies. Thus, the need to analyze fraud begins to take effect. Healthcare fraud analysis helps different health care organizations use predictable data methods in accounting and research activities.
With the growing trend of health care fraud in different parts of the world, the need for accurate identification is very important, which is drawing global attention to solutions to health fraud analysis. One of the key factors in promoting the adoption of the health fraud analysis market is the significant increase in the number of people using health care insurance, which increases the pressure on health care providers to protect themselves from any potential fraud and abuse. Also, the increasing number of healthcare BPOs and fraudulent identity management software, as well as the impact of media resources on the healthcare industry increases the need for a health fraud analysis market.
DRIVERS
The prevalence of pharmacy-related fraud is on the rise
In the healthcare industry, there are several instances of fraud
A rise in the number of people looking for health insurance
Model for evaluating prepayment
Exceptional ROI
RESTRAINTS
Data collection in Medicaid programmes has some limitations.
A reluctance to use fraud analytics in healthcare
OPPORTUNITIES
In underdeveloped countries, the use of healthcare fraud analytics is growing.
The rise of social media and its implications for healthcare
Artificial Intelligence Role in Detecting Health-Care Fraud
CHALLENGES
Shortage of qualified employees
Deployment takes a long time, and upgrades are required on a regular basis.
The worldwide healthcare fraud analytics industry is confronted with numerous obstacles. Travel bans and quarantines, halts in indoor/outdoor activities, temporary business shutdowns, supply demand changes, stock market volatility, dwindling corporate 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 incidents in the healthcare industry. Several healthcare providers and professionals have been caught in the act of defrauding patients for financial gain. Patients' fraudulent acts in the healthcare sector include fraudulently obtaining sickness certificates, prescription fraud, and evasion of medical payments.
By Solution Type
Part of the descriptive statistics hold the largest market share of about 40.0% by 2023, due to its high acceptance due to its ease of use. Uses current and historical data to identify styles and relationships. This helps to identify potential fraud in a better way. It also serves as the basis for the effective use of descriptive and predictive statistics. This also supports partial growth.
Part of the forecast figures are expected to confirm rapid growth over the projected period. The most effective way to prevent fraud is to identify them before claims are made. As a result, healthcare providers have begun to adopt predictable statistical solutions. These solutions identify possible patterns of fraud, and then develop specific rules to mark certain claims.
By Delivery Model
The on-premise segment had the biggest revenue share due to the convenience of accessing data on-site, such as in hospitals, which has resulted 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 dataset. This could imply a significant financial investment in data storage and security.
During the forecast period, the cloud-based segment is expected to develop at the fastest rate, as it has been the emerging delivery option because it provides a bigger virtual area to store data for a large number of patients. This is a more economical and commercially feasible choice for businesses. More security worries about data theft and less privacy are limitations of this category.
By Solution Type
Descriptive Analytics
By Delivery Model
On-premises
Cloud-based
By Application
Insurance Claim Review
Postpayment Review
Prepayment Review
Pharmacy billing Issue
Payment Integrity
Others
By End User
Public & Government Agencies
Private Insurance Payers
Third-party Service Providers
Employers
North America, Europe, Latin America, the Middle East, Asia Pacific, and Africa are the continents represented. In 2023, the healthcare fraud analytics market in North America accounted for the biggest proportion. The large majority of individuals with health insurance, rising healthcare fraud, favorable government anti-fraud initiatives, pressure to cut healthcare costs, technological innovations, and greater service and product availability in this region are all factors that contribute to the region's significant market share. Furthermore, North America is home to the majority of the market's main players in healthcare fraud detection.
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REGIONAL COVERAGE:
North America
USA
Canada
Mexico
Europe
Germany
UK
France
Italy
Spain
The Netherlands
Rest of Europe
Asia-Pacific
Japan
south Korea
China
India
Australia
Rest of Asia-Pacific
The Middle East & Africa
Israel
UAE
South Africa
Rest of Middle East & Africa
Latin America
Brazil
Argentina
Rest of Latin America
Some of the major key players of Healthcare Fraud Analytics Market are as follows: Cotiviti, Inc, Conduent Inc, DXC Technology, EXL Service Holdings Inc., HCL Technologies Limited, IBM, OSP Labs, Optum Inc., SAS Institute Inc., Wipro Limited, and other players.
| Report Attributes | Details |
|---|---|
| Market Size in 2022 | US$ 2.42 Billion |
| Market Size by 2030 | US$ 14.01 Billion |
| CAGR | CAGR of 24.5% From 2024 to 2031 |
| Base Year | 2023 |
| Forecast Period | 2024-2031 |
| Historical Data | 2020-2022 |
| Report Scope & Coverage | Market Size, Segments Analysis, Competitive Landscape, Regional Analysis, DROC & SWOT Analysis, Forecast Outlook |
| Key Segments | • By Solution Type (Descriptive Analytics, Prescriptive Analytics, Predictive Analytics) • By Delivery Model (On-premises, Cloud-based) • By Application (Insurance Claim Review (Post payment Review, Prepayment Review), Pharmacy billing Issue, Payment Integrity, Others) • By End User (Public & Government Agencies, Private Insurance Payers, Third-party Service Providers, Employers) |
| Regional Analysis/Coverage | North America (USA, Canada, Mexico), Europe (Germany, UK, France, Italy, Spain, Netherlands, Rest of Europe), Asia-Pacific (Japan, South Korea, China, India, Australia, Rest of Asia-Pacific), The Middle East & Africa (Israel, UAE, South Africa, Rest of Middle East & Africa), Latin America (Brazil, Argentina, Rest of Latin America) |
| Company Profiles | Healthcare Fraud Analytics Market are as follows: Cotiviti, Inc, Conduent Inc, DXC Technology, EXL Service Holdings Inc., HCL Technologies Limited, IBM, OSP Labs, Optum Inc., SAS Institute Inc., Wipro Limited, and other players. |
| DRIVERS | • The prevalence of pharmacy-related fraud is on the rise • In the healthcare industry, there are several instances of fraud • A rise in the number of people looking for health insurance |
| RESTRAINTS | • Data collection in Medicaid programmes has some limitations. • A reluctance to use fraud analytics in healthcare |
Ans: The Healthcare Fraud Analytics Market is to Reach US$ 14.01 billion by 2031.
The challenges faced by Healthcare Fraud Analytics is Shortage of qualified employees, Deployment takes a long time, and upgrades are required on a regular basis.
The by type is divided into 3 sub segments is Descriptive Analytics, Prescriptive Analytics, Predictive Analytics
Healthcare fraud analytics market in North America accounted for the biggest proportion.
Ans: The Healthcare Fraud Analytics Market is growing at a CAGR of 24.5% over the forecast period 2024-2031.
Table of Contents
1. Introduction
1.1 Market Definition
1.2 Scope
1.3 Research Assumptions
2. Research Methodology
3. Market Dynamics
3.1 Drivers
3.2 Restraints
3.3 Opportunities
3.4 Challenges
4. Impact Analysis
4.1 COVID-19 Impact Analysis
4.2 Impact of Ukraine- Russia War
4.3 Impact of Ongoing Recession
4.3.1 Introduction
4.3.2 Impact on major economies
4.3.2.1 US
4.3.2.2 Canada
4.3.2.3 Germany
4.3.2.4 France
4.3.2.5 United Kingdom
4.3.2.6 China
4.3.2.7 Japan
4.3.2.8 South Korea
4.3.2.9 Rest of the World
5. Value Chain Analysis
6. Porter’s 5 forces model
7. PEST Analysis
8. Healthcare Fraud Analytics Segmentation, By Solution Type
8.1 Descriptive Analytics
8.2 Prescriptive Analytics
8.3 Predictive Analytics
9. Healthcare Fraud Analytics Segmentation, By Delivery Model
9.1 On-premises
10.1Cloud-based
10. Healthcare Fraud Analytics Segmentation, By Application
10.1 Insurance Claim Review
10.1.1 Postpayment Review
10.1.2Prepayment Review
10.2Pharmacy billing Issue
10.3Payment Integrity
10.4 Others
11. Healthcare Fraud Analytics Segmentation, By End User
11.1 Public & Government Agencies
11.2 Private Insurance Payers
11.3 Third-party Service Providers
11.4 Employers
12. Regional Analysis
12.1 Introduction
12.2 North America
12.2.1 USA
12.2.2 Canada
12.2.3 Mexico
12.3 Europe
12.3.1 Germany
12.3.2 UK
12.3.3 France
12.3.4 Italy
12.3.5 Spain
12.3.6 The Netherlands
12.3.7 Rest of Europe
12.4 Asia-Pacific
12.4.1 Japan
12.4.2 South Korea
12.4.3 China
12.4.4 India
12.4.5 Australia
12.4.6 Rest of Asia-Pacific
12.5 The Middle East & Africa
12.5.1 Israel
12.5.2 UAE
12.5.3 South Africa
12.5.4 Rest
12.6 Latin America
12.6.1 Brazil
12.6.2 Argentina
12.6.3 Rest of Latin America
13. Company Profiles
13.1 Wipro Limited
13.1.1 Financial
13.1.2 Products/ Services Offered
13.1.3 SWOT Analysis
13.1.4 The SNS view
13.2 Cotiviti, Inc
13.3 Conduent, Inc
13.4 DXC Technology
13.5 EXL Service Holdings Inc
13.6 HCL Technologies Limited
13.7 IBM
13.8 OSP Labs
13.9 Optum Inc
13.10 SAS Institute Inc
14. Competitive Landscape
14.1 Competitive Benchmark
14.2 Market Share Analysis
14.3 Recent Developments
15. Conclusion
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