Medical Payment Fraud Detection Market Research Report - Forecast till 2027

Medical Payment Fraud Detection Market: By Type (Descriptive Analytics, Predictive Analytics and Prescriptive Analytics), Component (Services and Software), Delivery model (On-Premise and Cloud-Based), Source of service (In-House and Outsourced), End User (Private Insurance Payers, Public/ Government Agencies and Third-Party Service Providers) and Region (Americas, Europe, Asia-Pacific and the Middle East and Africa) - Forecast to 2027

ID: MRFR/MED/8300-HCR | February 2021 | Region: Global | 120 pages

Medical Payment Fraud Detection Market Forecast


Medical Payment Fraud Detection Market is expected to hold a value of USD 5786.44 Million by 2027 and medical payment fraud detection market is expected to register a growth of 25.2% from 2020 to 2027.


Market Synopsis


Medical fraud is increasingly apperceived as one of the social concerns. Healthcare fraud varies, but generally, it involves filing dishonest health claims for profit. The combination of fear loosened healthcare regulations, and expected stimulus payments in response to the COVID 19 pandemic could unleash an unprecedented surge of healthcare scams and fraud. The rising number of patients opting for health insurance, increasing pressure of fraud, and abuse on healthcare spending are the key factors that are expected to drive the medical payment fraud detection market growth. For instance, according to the Centers for Disease Control and Prevention, 2018, report, 65.1% of people under the age of 65, in the US opted for private healthcare insurance. Moreover, a large number of fraudulent activities, rising healthcare expenditures, and growing pressure to increase operational efficiency and reduce healthcare spending are also expected to boost medical payment fraud detection market growth.


Market Influencer


An outbreak of COVID 19, leading to increased healthcare scams and fraud.


Medical Payment Fraud Detection Market Drivers



  • Payments in response to the COVID 19 pandemic could unleash an unpredicted surge of healthcare scams and frauds.



  • Rising number of patients opting for health insurance. Health insurance provides people with a much needed financial backlog at the time of medical emergencies. One of the ways to be financially prepared against uncertain health risks is by buying health insurance.



  • Large number of fraudulent activities. In 2018, USD 3.6 trillion was spent on healthcare in the US, representing billions of health insurance claims. It was an undisputed reality that some of these claims were fraudulent.



  • Increasing pressure of fraud and abuse on healthcare spending.



  • Rising healthcare expenditure. According to the World Health Organization (WHO) report, 2016, the rise in healthcare expenditure in low and middle-income countries was approximately 6% per annum as compared to 4% in high-income countries.



  • Growing pressure to increase operational efficiency and reduce healthcare spending.


Market Restraints



  • Lack of skilled professionals.

  • Unwillingness to adapt the fraud analytic system in developing countries.


Medical Payment Fraud Detection Market Segmentation


By Type



  • Descriptive Analytics: The descriptive analytics segment is the largest growing segment, as it forms the base for the effective application of predictive and prescriptive analytics. Furthermore, this type of analytics uses historical data to analyze the changes. Hence, it is used to analyze the revenue during a certain period.



  • Predictive Analytics: This identifies patterns that are potentially fraudulent and then develops sets of rules and flag certain claims.



  • Prescriptive Analytics: The prescriptive analytics segment is the fastest-growing segment owing to the high demand for technology. Moreover, this enables medical decision-makers to optimize business outcomes by recommending the best course of action for patients or providers. It estimates the likelihood of a future outcome based on patterns in the historical data.


By Component



  • Services: This segment holds the largest market share owing to a wide area of application such as monitoring transactions, medical payment patient check-in, insurance eligibility and verification, medical coding of diagnosis, procedures, and modifiers, charge entry, claims submission, and payment posting.



  • Software: This segment is the fastest-growing segment due to a rise in system integration, processing services, outsourcing, and packaged software support and installations with security measures. Moreover, medical payment through software application improves reimbursement rates, optimize revenue, and sustain the financial health of businesses.


By Delivery Model



  • On-premise: This stores all data on a physical server that are on respective medical site, and server management either remain own responsibility or outsourced to an IT provider.



  • Cloud-based: The factor such as the advancement of technology and the development of various artificial intelligence techniques leads the cloud-based segment as the largest and fastest-growing segment during the forecast period. This stores all information on the internet ‘the cloud’, which is then backed up by premium security data centers.


By Source of Service



  • In-house: Staff of the clinic or health department is responsible for all aspects of revenue cycle management. They submit claims to a clearinghouse or the insurance company for reimbursement, set charges, collect patient fees, and manages the account receivables.



  • Outsourced: Providers may outsource their medical payment to a third party known as a medical billing service. These billing services typically take a percentage of a practice’s collections as payment for managing many aspects of the clinic's revenue cycle management.


By End-User



  • Private Insurance Payers: Private payers are insurance companies that offer different types of plans that must meet or exceed basic standards.



  • Public/Government Agencies: Federal and state agencies that reimburse healthcare providers can significantly enhance their risk modeling and fraud collection.



  • Third-Party Service Providers: Third-party service providers have the responsibility of managing claims, getting reimbursement from the insurance company, and paying the healthcare provider.


By Region



  • Americas: Review of insurance claims plays a major role in healthcare fraud detection. As per the estimates of the National Healthcare Anti-Fraud Association (NHCAA), Healthcare fraud costs the US around USD 68 billion annually. Hence, healthcare insurance fraud detection leads to drive the medical payment fraud detection market.



  • Europe: Europe holds the second-largest market. According to the Organization for Economic Cooperation and Development (OECD) report, 2018, over 75% of health spending was financed through government and compulsory insurance across European countries. Rising healthcare expenditure is expected to boost the medical payment fraud detection market growth.



  • Asia-Pacific: Asia-Pacific is expected to be the fastest-growing region. According to the Asian Hospital and Healthcare Management report, the private health insurance market is projected to continue expanding with almost 3 million actively seek health insurance by end of 2020, and that number is projected to continue increasing. Moreover, a rising number of patients are opting for healthcare insurance which is expected to increase the medical payment fraud detection market growth during the forecast period.



  • Middle East and Africa: The medical payment fraud detection market is expected for remarkable growth in the development of healthcare services. Rise in healthcare expenditure and growing pressure to increase operational efficiency are expected to boost the medical payment fraud detection market growth.


Medical Payment Fraud Detection Market  Key Players



  • LexisNexis Risk Solutions

  • International Business Machines Corporation

  • Optuminsight

  • OSP Labs

  • DXC Technology Company

  • Unitedhealth Group

  • SAS Institute

  • Fair Isaac Corporation

  • EXL Service Holdings, Inc.

  • CGI GROUP



Report Scope:
Report Attribute/Metric Details
  Market Size   2027: USD 5786.44 Million
  CAGR   25.2%(2020–2027)
  Base Year   2019
  Forecast Period   2027
  Historical Data   2018
  Forecast Units   Value (USD Million)
  Report Coverage    Revenue Forecast, Competitive Landscape, Growth Factors, and Trends
  Segments Covered   By Type, Component, Delivery model, Source of service, End Use and Region
  Geographies Covered    North America, Europe, Asia-Pacific, and Rest of the World (RoW)
  Key Vendors   LexisNexis Risk Solutions, International Business Machines Corporation, Optuminsight, OSP Labs, DXC Technology Company, Unitedhealth Group, SAS Institute, Fair Isaac Corporation, EXL Service Holdings, Inc., CGI GROUP
  Key Market Opportunities

  • The rising number of patients opting for health insurance
  • Increasing pressure of fraud
  • Abuse on healthcare spending
  •   Key Market Drivers   Payments in response to the COVID 19 pandemic could unleash an unpredicted surge of healthcare scams and frauds.