Fraud analytics is the efficient use of data analytics and related business insights developed through statistical, quantitative, predictive, comparative, cognitive, and other emerging applied analytical models for detecting and preventing healthcare fraud.
The global healthcare fraud analytics market is projected to reach USD 5.0 billion by 2026 from USD 1.5 billion in 2021, at a CAGR of 26.7% during the forecast period. Market growth can be attributed to a large number of fraudulent activities in healthcare, the increasing number of patients seeking health insurance, high returns on investment, and the rising number of pharmacy claims-related frauds. However, the dearth of skilled personnel is expected to restrain the growth of this market.
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The healthcare industry has been witnessing a number of cases of fraud, done by patients, doctors, physicians, and other medical specialists. Many healthcare providers and specialists have been observed to be engaged in fraudulent activities, for the sake of profit. In the healthcare sector, fraudulent activities done by patients include the fraudulent procurement of sickness certificates, prescription fraud, and evasion of medical charges.
A couple of reasons contributing to the growth of the health insurance market include the rise in the aging population, growth in healthcare expenditure, and increased burden of diseases. In the US, the number of citizens without health insurance has significantly decreased, from 48 million in 2010 to 28.6 million in 2016. In 2017, 12.2 million people signed up for or renewed their health insurance during the 2017 open enrollment period (Source: National Center for Health Statistics).
This growth is aided by the increasing affordability of health insurance for the middle class in this region and the rising awareness regarding the benefits of health insurance. In the UAE, as per a new regulatory policy (2017), any citizen residing and working in the UAE needs to be insured medically.
Major players in this market include IBM Corporation (US), Optum, Inc. (US), Cotiviti, Inc. (US), Change Healthcare (US), Fair Isaac Corporation (US), SAS Institute Inc. (US), EXLService Holdings, Inc. (US), Wipro Limited (India), Conduent, Incorporated (US), CGI Inc. (Canada), HCL Technologies Limited (India), Qlarant, Inc. (US), DXC Technology (US), Northrop Grumman Corporation (US), LexisNexis (US), Healthcare Fraud Shield (US), Sharecare, Inc. (US), FraudLens, Inc. (US), HMS Holding Corp. (US), Codoxo (US), H20.ai (US), Pondera Solutions, Inc. (US), FRISS (The Netherlands), Multiplan (US), FraudScope (US), and OSP Labs (US).
Research Developments Analysis
1. In January 2019, LexisNexis Risk Solutions collaborated with QuadraMed to enable patient identification capabilities and reduce the number of duplicate identities & fraudulent claims.
2. In August 2018, Verscend Technologies acquired Cotiviti Holdings. This acquisition helped improve the affordability of fraud detection solutions.
3. In June 2018, SAS Institute & Prime Therapeutics LLC teamed up, enabling Prime Therapeutics to utilize SAS’s analytic capabilities to combat the opioid crisis in the US