Healthcare Fraud Detection Market - Growth, Trends, COVID-19 Impact, and Forecasts (2021 - 2026)

Market Overview

The healthcare fraud detection market was valued at USD 679.18 million in 2018, and it is expected to reach USD 2,540.29 million by 2024, registering a CAGR of 24.59%, during the forecast period (2019-2024).

• 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 the operational efficiency and reduce healthcare spending, and surging fraudulent activities in the healthcare sector, globally.
•  The healthcare industry has been witnessing a number of cases of frauds, 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.
• Medical professionals are also involved in fraudulent activities, such as prescription fraud by pharmacists and fraud and errors concerning payments for medical tests, facility services, and consultations.
• Globally, the healthcare expenditure is rising, especially in the low- and middle-income countries. As per the World Health Organization’s 2016 report, the rise in healthcare expenditure in these countries was approximately 6% per annum, as compared to 4% in the high-income countries.
• According to the WHO’s report on global healthcare expenditure (2016), the governments in the low- and middle-income countries spend USD 60 per person on healthcare, while those in the upper-middle-income countries spend USD 270.
• 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 have to pay from their own pockets, due to less contribution from the governments toward healthcare expenditure.
• Most of the insurance companies are adopting fraud detection software, due to the rising availability of the same in the 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 the early detection of errors in claim submissions, duplication of claims, etc., in order to minimize the healthcare spending and improve the efficiency.

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Key Market Trends

By Application, the Review of Insurance Claims Segment is Expected to Hold the Major Share in the Market

Healthcare fraud detection solutions play 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, 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 and enabling loss control units to achieve higher coverage with low false positive rates. Moreover, the quality and quantity of the available data have huge impacts 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 presence of such organizations is expected to create more awareness among the users, thereby, leading to high demand for healthcare fraud detection solutions.

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