New York, United States, Feb. 03, 2025 (GLOBE NEWSWIRE) — Healthcare fraud analytics entails applying advanced analytics techniques and data analysis to detect and stop fraudulent activities within the healthcare industry. The importance of this field has increased as healthcare providers, insurers, and government agencies strive to identify and counter fraudulent activities that may lead to financial setbacks and compromised patient care.
Healthcare fraud analytics can identify patterns associated with fraudulent behavior by employing data modeling and machine learning methodologies. Duplicate claims, inconsistent patient information, atypical invoicing patterns, and other irregularities are examples of such patterns. Healthcare fraud analytics plays a critical role in preserving the integrity of the healthcare system by identifying and preventing fraudulent activities.
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Market Dynamics
Rising Incidents of Healthcare Fraud drive the Global Market
The healthcare sector has consistently struggled with the enduring problem of healthcare fraud. The widespread occurrence of fraudulent activities in the healthcare industry has become a significant impetus for implementing healthcare fraud analytics solutions. Various deceitful practices are classified as fraudulent activities, including but not limited to making false assertions, identity theft, and billing schemes.
Based on data from the United States Sentencing Commission, healthcare fraud accounted for 431 cases during the fiscal year of 2022. This accounts for approximately 8.4% of the total number of offenses involving fraud, property damage, and theft. Since the fiscal year of 2018, the number of individuals convicted of healthcare fraud has increased by 1.4%. Consequently, an increase in healthcare fraud is propelling the worldwide market for healthcare fraud analytics.
Technological Advancements Creates Tremendous Opportunities
The capabilities of fraud detection systems have been enhanced by technological developments, specifically in artificial intelligence, machine learning, and data analytics. These technologies effectively mitigate financial and administrative costs through the expedited and more accurate detection and prevention of fraudulent activities compared to traditional approaches. Healthcare organizations use these technologies to analyze enormous datasets and identify patterns for forecasting fraudulent behavior.
For instance, AI assists the Indian government’s health scheme in combating fraud. The Health Ministry data accessed by The Hindu in July 2023 indicates that 210 hospitals were de-empanelled, 5.3 lakh Ayushman cards were disabled, and a penalty of INR 9.5 crores was recovered. These actions were taken in response to information about fraud obtained through an anti-fraud initiative utilizing machine learning and artificial intelligence to protect the largest global government-run insurance scheme, the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana. Therefore, AI can improve fraud detection and prevention, generating opportunities for vendors engaged in the healthcare fraud analytics market.
Regional Analysis
North America is the most significant global healthcare fraud analytics market shareholder and is expected to expand substantially during the forecast period. The escalating healthcare expenditures, the presence of advanced healthcare infrastructure, the expanding adoption of healthcare IT, and the rise in fraud cases all contribute to the North American region’s dominance. For instance, criminal allegations were recently disclosed by the Department of Justice in the United States against 138 defendants, including 42 physicians, nurses, and other licensed medical professionals. These allegations have been lodged in thirty-one federal districts nationwide. The defendants are presumed to have participated in numerous healthcare fraud schemes, which resulted in an approximate loss of USD 1.4 billion when taken as a whole. The allegations concern a projected sum of USD 1.1 billion in fraudulent operations conducted via telemedicine.
Furthermore, additional funds were targeted: USD 133 million associated with substance abuse treatment facilities, commonly known as “sober homes,” USD 29 million in healthcare fraud related to COVID-19, and USD 160 million linked to other instances of healthcare fraud and illegal distribution of opioids across the country. These factors are expected to stimulate the expansion of the regional market.
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Key Highlights
- The global healthcare fraud analytics market size was valued at USD 3.18 billion in 2024 and is projected to reach from USD 3.92 billion in 2025 to USD 25.48 billion by 2033, growing at a CAGR of 23.12% during the forecast period (2025-2033).
- Based on the solution type, the global healthcare fraud analytics market is segmented into descriptive, predictive, and prescriptive analytics. The descriptive analytics segment is the highest contributor to the market.
- Based on the deployment model, the global healthcare fraud analytics market is divided into on-premises and cloud-based. The on-premises segment is the largest contributor to the market.
- Based on application, the global healthcare fraud analytics market is divided into insurance claim review, pharmacy billing issues, payment integrity, and others. The insurance claim review segment is the largest contributor to the market.
- Based on end-users, the global healthcare fraud analytics market is bifurcated into public and government agencies, private insurance payers, third-party service providers, and employers. The public and government agencies segment dominates the global market.
- North America is the most significant global healthcare fraud analytics market shareholder and is expected to expand substantially during the forecast period.
Competitive Players
- IBM
- Cotiviti, Inc.
- DXC Technology
- Optum, Inc.
- Verisk Analytics
- SAS Institute, Inc.
- EXL Service Holdings, Inc.
- Wipro Limited
- LexisNexis Risk Solutions
- Conduent, Inc.
- HCL Technologies Limited
- OSP Labs
Recent Developments
- May 2023: Teradata and FICO announced that they are set to introduce integrated advanced analytical solutions that target supply chain optimization, insurance claims, and real-time payment fraud. Integrating data, analytics, and insights within a unified environment facilitates the efficient creation of solutions to address various use cases in sectors like finance, healthcare, retail, manufacturing, and travel.
- June 2023: Jack Henry™ introduced Payrailz® Fraud Monitor, an AI-powered, cloud-native component of the Payrailz Digital Payments Platform. This feature detects fraudulent activities in real-time, beginning with the initiation of payment transactions.
Segmentation
By Solution Type
- Descriptive Analytics
- Prescriptive Analytics
- Predictive Analytics
By Delivery Model
- On-premises
- Cloud-based
By Applications
- Insurance Claim Review
- Pharmacy Billing Issue
- Payment Integrity
- Others
By End-User
- Public and Government Agencies
- Private Insurance Payers
- Third-party Service Providers
- Employers
By Region
- North America
- Europe
- Asia Pacific
- Middle East And Africa
- Latin America
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