Healthcare Fraud Detection Market Size

Global Healthcare Fraud Detection Market Overview

Healthcare Fraud Detection Market Size was valued at USD 3.8 billion in 2023 and is projected to grow from USD 4.92 Billion in 2024 to USD 30.69 billion by 2032, exhibiting a compound annual growth rate (CAGR) of 25.71% during the forecast period (2024 - 2032). The rising number of fraud cases in the healthcare industry, the growing focus on controlling healthcare costs, and technological advancements introducing advanced analytical techniques are the key market drivers enhancing market growth.

Source: Secondary Research, Primary Research, MRFR Database and Analyst Review

Auditing accounts, medical claims, and healthcare funds are steps in discovering healthcare fraud. Medical fraud cases, including those involving cash, claims, and insurance fraud in the healthcare industry, are rising. Machine learning approaches help increase the forecasting accuracy of loss control units and provide greater coverage with fewer false-positive results. In addition, the quantity and quality of the data that are accessible have a much greater influence on the forecast accuracy than does the algorithm's quality. Healthcare fraud detection technology also aids in reducing waste, fraud, and abuse in the industry. As the healthcare business employs more and more new software that utilizes data mining and artificial intelligence, the market size for healthcare fraud detection is expected to expand quickly. 

This market is also expected to grow due to increased analysis, services, insurance claim reviews, and payment integrity. Additionally, a growing number of patients are taking advantage of health insurance, increasing pressure against abuse and fraud, and greater healthcare fraud are all contributing to the growth of the global market for healthcare fraud detection. Additionally, the healthcare sector's usage of various innovative software that utilizes data mining and artificial intelligence is fueling market expansion. Healthcare fraud is entirely a deliberate fabrication of facts by healthcare personnel or patients, which can result in unlawful payments or benefits. The market is also driven by rising healthcare costs, a rise in the number of patients choosing health insurance, mounting pressure to improve operational effectiveness and cut costs, and increased fraud in the global healthcare industry.

News:At the outset of this month at NAMPI 2023, the District of Columbia Department of Health Care Finance Division of Program Integrity highlighted its strategic partnership with Sandata Technologies, the industry-leading force in homecare that prevents fraud, waste, and abuse (FWA) in Medicaid. This partnership is part of the District of Columbia Department of Health Care Finance's ongoing effort to protect the integrity of its Medicaid program. At the conference, representatives from the two organizations participated in a panel discussion about their collaboration in reducing FWA.

Healthcare Fraud Detection Market Trends

• Increasing number of patients seeking health insurance to boost the market growth

Healthcare fraud detection involves account audits, medical claims, and healthcare fund audits. Medical insurance fund and other medical fraud cases fraud, claims, and Medicare fraud in the healthcare industry have increased. In addition, the healthcare fraud detection market helps prevent healthcare fraud, waste, and abuse. Healthcare fraud is an outright misrepresentation of fact or deliberate deception by a healthcare professional or patient, resulting in unauthorized payments or benefits. Some examples of healthcare fraud include falsifying data from Physicians, multiple claims from different providers for the same patient, claims for services submitted, Failure to provide, misrepresenting the dates, frequency, etc.

The healthcare fraud detection market size is expected to experience rapid growth owing to various new software the healthcare industry uses, technologies based on data mining and artificial intelligence. Also, the global healthcare fraud detection market share is expanding owing to increasing fraud. In healthcare, pressures for abuse and fraud have increased, and patients benefiting from Medicare have increased. Moreover, various new software based on data mining and artificial intelligence being used in the healthcare industry is driving market growth.

Furthermore, the increased use of advanced analytics, machine learning and artificial intelligence in healthcare has contributed to the market. However, data breaches in the healthcare industry are rising, and related awareness levels are decreasing; healthcare fraud analytics solutions in emerging countries are poised to suppress the healthcare fraud detection market growth. The increased number of fraudulent healthcare activities and the increased number of patients seeking treatment medical insurance is the key driver that will boost the market growth amid medical fraud test market forecasts. Therefore, the Healthcare Fraud Detection market CAGR has been increasing globally in recent years. These are important factors driving the Healthcare Fraud Detection market revenue growth.

Healthcare Fraud Detection Market Segment Insights

Healthcare Fraud Detection Type Insights

The global Healthcare Fraud Detection market segmentation, based on Type, includes descriptive, predictive, and prescriptive analytics. The descriptive analytics segment held the majority share in 2022, contributing to around ~40% of the global Healthcare Fraud Detection market revenue, owing to its wide adoption and ease of use. It utilizes current and historical data to identify trends and relationships. This helps to identify possible fraud in a better way. It can also serve as the basis for applying prescriptive and predictive analytics effectively. This further supports the growth of the segment.

The healthcare predictive analytics segment is expected to witness the fastest growth during the forecast period. The most effective way to prevent fraud is to identify claims before they are paid out. As a result, healthcare payers have started adopting predictive analytics solutions. These solutions identify potentially fraudulent patterns and then develop rules to flag certain claims.

Healthcare Fraud Detection Component Insights

Components have bifurcated the global Healthcare Fraud Detection market data into services and software. The healthcare fraud detection software market is growing steadily owing to the advent of technologically advanced software and its surging demand.

Figure 1: Healthcare Fraud Detection Market by Component, 2023 & 2032 (USD billion)

Source: Secondary Research, Primary Research, MRFR Database and Analyst Review

Healthcare Fraud Detection Delivery Model Insights

Based on the Delivery Model, the global Healthcare Fraud Detection Delivery Model has been segmented into the on-premises and cloud-based. The on-premises segment will hold the highest revenue share in 2021 at over 51% due to ease of access to data in the field (i.e., hospitals, etc.), better records management, data monitoring, and more. Current systems in small organizations are practical, but managing the data as it scales can take time and effort if the organization deals with large data sets. This can mean significant capital investment in data storage and security.

Healthcare Fraud Detection Application Insights

Based on application, global Healthcare Fraud Detection has been segmented into the insurance claims review and payment integrity. The insurance claims review segment holds the largest market share of over 35% in 2021, owing to the increasing adoption of health insurance, which also leads to increased fraudulent claims. This section is further divided into post-payment review and pre-payment review. The advance payment review segment will likely grow at the fastest CAGR due to rising healthcare providers' demand.

The pharmacy billing issues segment is also expected to witness significant growth owing to the rising number of medical billing frauds occurring in pharmacies. Likewise, the payment integrity segment will likely expand at a decent growth rate. Payment integrity is a tool that payers use to tighten administrative aspects to reduce costs.

Healthcare Fraud Detection End User Insights

Based on end users, the global Healthcare Fraud Detection Delivery Model has been segmented into private insurance payers, public/government agencies and third-party service providers. Public/government agencies accounted for over 41.0% of the healthcare fraud analytics market in 2021. Key factors contributing to this huge share include high patient volume in government hospitals and government agencies' high vulnerability to fraudulent activities due to the lack of technologically advanced infrastructure, especially in developing countries.

The employer segment is expected to grow at the highest CAGR during the forecast period owing to the increasing demand from employers for healthcare fraud analytics for better cost management. The private insurance payers segment is also estimated to witness significant growth owing to the increasing use of fraud analytics solutions to combat rising monetary losses.

News:According to Mastercard and HealthLock, this partnership would aid consumers in avoiding medical billing fraud and claim blunders. Users of Mastercard health savings accounts and flexible spending accounts now have access to Healthlock's platform, which enables them to monitor all medical claims in one location, stop fraud, perhaps save costs, and overturn claims that have been denied. This relationship was recently revealed. Customers can review each medical insurance claim using the HealthLock platform, which groups them all on a single dashboard. The collaboration comes when customers are more eager than ever to use a comprehensive digital healthcare platform that gives them access to insurance details, pharmacy services, scheduling appointments and check-ins, and provider online portals.

Healthcare Fraud Detection Regional Insights

By Region, the study provides market insights into North America, Europe, Asia-Pacific and the Rest of the World. In North America, the Healthcare Fraud Detection market accounted for USD 1.3 billion in 2022 and is expected to exhibit a significant CAGR growth during the study period. The Americas topped the list with a global share of 45.8%. The Americas has emerged as a lucrative market owing to the rising usage of technologically innovative products, supportive reimbursement policies, and rising spending on healthcare analytics services. Numerous world-renowned players offering a wide range of healthcare fraud detection solutions have also boosted the market share in the Region.

Further, the major countries studied in the market report are The U.S., Canada, Germany, France, UK, Italy, Spain, China, Japan, India, Australia, South Korea, and Brazil.

Figure 2: HEALTHCARE FRAUD DETECTION MARKET SHARE BY REGION 2022 (%)

Source: Secondary Research, Primary Research, MRFR Database and Analyst Review

Europe's Healthcare Fraud Detection market accounts for the second-largest market share. Europe is ranked No. 1 in the healthcare fraud detection management system market owing to the high adoption of cloud-based analytics solutions, the growing influence of social media in the healthcare industry, and the growing integration of artificial intelligence in various healthcare solutions and services. Further, the Germany Healthcare Fraud Detection market held the largest market share, and the U.K. Healthcare Fraud Detection market was the fastest-growing market in the European Region.

The Asia-Pacific Healthcare Fraud Detection Market is expected to grow at the fastest CAGR from 2024 to 2032. The Asia Pacific region will witness lucrative growth at a high CAGR. The healthcare fraud detection market size in the Asia Pacific is expanding on the back of a surging number of government anti-fraud initiatives, reduction in healthcare costs, technological advancements, and increasing demand for increased service and product availability. Rising threats in the Region, especially in India and China, have prompted major companies to focus more on developing advanced healthcare fraud prevention services, helping boost the market growth. Moreover, the rising popularity of medical tourism and growing demand from the pharmaceutical industry are likely to be key trends in this Region's healthcare fraud detection market. Moreover, the China Healthcare Fraud Detection market held the largest market share, and the India Healthcare Fraud Detection market was the fastest-growing in Asia-Pacific.

Healthcare Fraud Detection Key Market Players & Competitive Insights

Major market players are spending a lot on R&D to increase their product lines, which will help the Healthcare Fraud Detection market grow even more. Market participants are also taking various strategic initiatives to grow their worldwide footprint, with key market developments such as new product launches, contractual agreements, mergers and acquisitions, increased investments, and collaboration with other organizations. Competitors in the Healthcare Fraud Detection Delivery Model must offer cost-effective items to expand and survive in an increasingly competitive and rising market environment.

One of the primary business strategies adopted by manufacturers in the global Healthcare Fraud Detection Delivery Model to benefit clients and expand the market sector is to manufacture locally to reduce operating costs. The Healthcare Fraud Detection Delivery Model has provided medicine with some of the most significant benefits in recent years. In the Healthcare Fraud Detection markets, major players such as Medtronic Inc (Ireland), Abbott Laboratories (U.S.), Stryker Corporation (U.S.), and others are working on expanding the market demand by investing in research and development activities.

Wipro Limited is an Indian multinational company providing information technology, consulting and business process services. Thierry Delaporte has been CEO and Managing Director of Wipro since July 2020. Wipro's capabilities span cloud computing, cybersecurity, digital transformation, artificial intelligence, robotics, data analytics and other technology consulting services, serving clients in 167 countries. In December 2021, Wipro Limited acquired LeanSwift. This acquisition extends the capabilities of Wipro FullStride Cloud Services.

Also, LexisNexis is part of RELX Corporation, which sells data analysis products and various databases accessed through online portals, including portals for computer-aided legal research (CALR), newspaper searches, and consumer information. In the 1970s, LexisNexis began making legal and press documents more accessible electronically. As of 2006, the company held the world's largest electronic database of information related to legal and public records. In November 2020, LexisNexis Risk Solutions launched LexisNexis Emailage, an innovative fraud risk scoring service powered by email intelligence that enables companies to deliver a frictionless user experience through extensive fraud detection and prevention capabilities. The solution helps address these issues by enabling organizations to analyze risk efficiently, facilitate faster transactions, and address rapidly evolving fraud tactics during digital transactions.

Key Companies in the Healthcare Fraud Detection market include

• DXC Technology Company


• UnitedHealth Group


• SAS Institute Inc.


• WIPRO LIMITED


• EXLSERVICE Holdings Inc.


• International Business Machines Corporation (IBM)


• COTIVITI INC.


• McKesson Corporation


• CGI INC


• FAIR ISAAC Corporation


• LEXISNEXIS, among others

Healthcare Fraud Detection Delivery Model Developments

March 2022: Veriff released a new suite of biometric authentication solutions designed specifically for the healthcare industry. According to the company, the new product will utilize artificial intelligence and facial recognition technology to perform user identification.

February 2022: The Canadian Life and Health Insurance Association (CLHIA) launched an industry initiative to pool claims data and use advanced artificial intelligence tools to enhance the detection and investigation of benefit fraud.

Healthcare Fraud Detection Market Segmentation

Healthcare Fraud Detection Type Outlook

• Descriptive Analytics


• Predictive Analytics


• Prescriptive Analytics

Healthcare Fraud Detection Component Outlook

• Services


• Software

Healthcare Fraud Detection Delivery Model Outlook

• On-Premise


• Cloud-Based

Healthcare Fraud Detection Application Outlook

• Insurance Claims Review


• Payment Integrity

Healthcare Fraud Detection End User Outlook

• Private Insurance Payers


• Public/Government Agencies


• Third-Party Service Providers

Healthcare Fraud Detection Regional Outlook

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  North America

  
  
  
  
  • US
  
  
  • Canada
  
  
  
  


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  Europe

  
  
  
  
  • Germany
  
  
  • France
  
  
  • UK
  
  
  • Italy
  
  
  • Spain
  
  
  • Rest of Europe
  
  
  
  


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  Asia-Pacific

  
  
  
  
  • China
  
  
  • Japan
  
  
  • India
  
  
  • Australia
  
  
  • South Korea
  
  
  • Australia
  
  
  • Rest of Asia-Pacific
  
  
  
  


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  Rest of the World

  
  
  
  
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    Middle East

    
    
  
  
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    Africa

    
    
  
  
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    Latin America