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Healthcare Fraud Analytics Market by Solution Type (Descriptive, Predictive, Prescriptive), Application (Insurance Claim (Postpayment, Prepayment), Payment Integrity), Delivery (On-premise, Cloud), End User (Insurance, Government) - Global Forecast to 2025

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Date: 29-Jan-2020
No. of pages: 144
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The healthcare fraud analytics market is projected to reach USD 4.6 billion by 2025 from USD 1.2 billion in 2020 at a CAGR of 29.8%. The emergence of social network analytics, the adoption of technologies such as AI and blockchain, and the growing use of healthcare analytics for fraud detection in emerging nations like the APAC provide growth opportunities in this market. However, the time-consuming deployment of these solutions and the need for frequent updates are some challenges faced by end users of this market.

The on-demand segment is projected to witness the highest growth during the forecast period

On the basis of delivery model, the healthcare fraud analytics market is segmented into on-premise and on-demand models. The on-demand models include the cloud-based and web-based models. The on-demand segment is projected to register the highest CAGR during the forecast period. Factors such as on-demand self-serving analytics, the lack of up-front capital investments for hardware, extreme capacity flexibility, and a pay-as-you-go pricing model are driving the demand for on-demand fraud detection solutions.

The prepayment review model is projected to witness the highest growth during the forecast period

On the basis of application, the healthcare fraud analytics market is segmented into insurance claims review, pharmacy billing misuse, payment integrity, and other applications. The insurance claims review segment is further divided into post payment and prepayment review, with the latter expected to register the highest growth during the forecast period. This is mainly because the use of prepayment review protocols and analytics can help organizations proactively prevent fraud prior to payment, allowing rapid action to be taken. As a result, prepayment review solutions are expected to garner greater attention in the coming years.

The Asia Pacific to witness the highest growth during the forecast period

The Asia Pacific is expected to witness the highest growth during the forecast period (2020 to 2025), owing to factors such as the growing demand for health insurance and increasing collaborations & partnerships between governments and tech giants for leveraging fraud analytics capabilities.

A breakdown of primary participants involved in making this report is mentioned below:


  • By Company Type: Tier 1–45%, Tier 2–18%, and Tier 3–37%

  • By Designation: C Level–35%, Director Level–50%, Others–15%

  • By Region: North America–60%,Asia Pacific–22%, Europe–13%, Latin America–2%, Middle East and Africa–3%


Some of the major market players in the healthcare fraud analytics market are IBM Corporation (US), Optum (US), SAS Institute(US), Change Healthcare(US), EXL Service Holdings(US), Cotiviti (US), Wipro Limited (India), Conduent(US), HCL (India), Canadian Global Information Technology Group (Canada), DXC Technology Company (US), Northrop Grumman Corporation (US), LexisNexis Group (US), and Pondera Solutions (US).

Research Coverage:          

The report analyzes the healthcare fraud analytics market and aims at estimating the market size and future growth potential of this market based on various segmentations, such as solution type, delivery model, application, enduser, and region. It also covers the competitive leadership mapping, which analyzes the position of key market players and classifies them based on their capabilities. The report providesa competitive analysis of the key players in this market, along with their profiles, offerings, recent developments, and key market strategies.

Reasons to Buy the Report

The report will enrich established firms as well as new entrants/smaller firms to gauge the pulse of the market to help them garner a greater share of the market. Firms purchasing the report could use one or any combination of the below-mentioned strategies to strengthen their position in the market.

This report provides insights into the following pointers:


  • Market Penetration: Comprehensive information on the portfolios of top players in the global healthcare fraud analytics market. The report analyzes this market by solution type, delivery model, application, end user, and region.

  • Product Enhancement/Innovation: Detailed insights on upcoming technology trends in the global healthcare fraud analytics market

  • Market Development: Comprehensive information on the lucrative emerging markets

  • Market Diversification: Exhaustive information about growing geographies, recent developments, and collaborations in the healthcare fraud analytics market

  • Competitive Assessment: In-depth assessment of growth strategies, offerings, and capabilities of leading players in the global healthcare fraud analytics market

Healthcare Fraud Analytics Market by Solution Type (Descriptive, Predictive, Prescriptive), Application (Insurance Claim (Postpayment, Prepayment), Payment Integrity), Delivery (On-premise, Cloud), End User (Insurance, Government) - Global Forecast to 2025

Table of Contents

1 Introduction
1.1 Objectives of the Study
1.2 Market Definition
1.3 Market Scope
1.3.1 Markets Covered
1.3.2 Years Considered for the Study
1.4 Currency
1.5 Limitations
1.6 Stakeholders

2 Research Methodology
2.1 Research Approach
2.1.1 Secondary Sources
2.1.1.1 Key Data From Secondary Sources
2.1.2 Primary Sources
2.1.2.1 Key Data From Primary Sources
2.2 Market Size Estimation
2.3 Market Breakdown and Data Triangulation
2.4 Assumptions for the Study

3 Executive Summary

4 Premium Insights
4.1 Healthcare Fraud Analytics Market Overview
4.2 Asia Pacific: Market, By Solution Type and Application (2019)
4.3 Market: Geographic Growth Opportunities
4.4 Market: Regional Mix
4.5 Market: Developing vs Developed Regions

5 Market Overview
5.1 Introduction
5.2 Market Dynamics
5.2.1 Drivers
5.2.1.1 Large Number of Fraudulent Activities in Healthcare
5.2.1.2 Increasing Number of Patients Seeking Health Insurance
5.2.1.3 Prepayment Review Model
5.2.1.4 High Returns on Investment
5.2.1.5 Rise in Pharmacy Claims-Related Fraud
5.2.2 Restraints
5.2.2.1 Limitations in the Data Capturing Process in Medicaid Services
5.2.3 Opportunities
5.2.3.1 Adoption of Healthcare Fraud Analytics in Developing Countries
5.2.3.2 Emergence of Social Media and Its Impact on the Healthcare Industry
5.2.3.3 Role of AI in Healthcare Fraud Detection
5.2.4 Challenges
5.2.4.1 Dearth of Skilled Personnel
5.2.4.2 Time-Consuming Deployment and the Need for Frequent Upgrades

6 Industry Insights
6.1 Industry Trends
6.1.1 Shifting Focus From On-Premise Models to Cloud-Based On-Demand Models
6.1.2 Mergers and Acquisitions: the Most Adopted Strategy
6.1.3 Technological Advancements
6.1.4 New Use Case: Opioid Epidemic Crisis
6.1.5 End-User Trends: Adoption of Healthcare Fraud Analytics Solutions By Pharmacy Benefit Managers

7 Healthcare Fraud Analytics Market, By Solution Type
7.1 Introduction
7.2 Descriptive Analytics
7.2.1 Descriptive Analytics Segment Accounted for the Largest Market Share
7.3 Predictive Analytics
7.3.1 Predictive Analytics Helps in Simulating Future Events & Trends That Can Enable Payers to Predict Preventable Events
7.4 Prescriptive Analytics
7.4.1 Prescriptive Models Offer Additional Advantages Relating to the Investigation of Suspicious Behavior to Generate Comprehensive Insights

8 Healthcare Fraud Analytics Market, By Delivery Model
8.1 Introduction
8.2 On-Premise Delivery Models
8.2.1 On-Premise Models Account for the Largest Share of the Market
8.3 On-Demand Delivery Models
8.3.1 Cloud-Based Delivery Models Offer Organizations Increased Scalability and Speed

9 Healthcare Fraud Analytics Market, By Application
9.1 Introduction
9.2 Insurance Claims Review
9.2.1 Postpayment Review
9.2.1.1 Postpayment Review Dominated the Healthcare Fraud Analytics Insurance Claims Review Market
9.2.2 Prepayment Review
9.2.2.1 The Majority of Prepayment Models Use Predictive Analytics to Detect Fraud and Stop Fraudulent Claims Payments
9.3 Pharmacy Billing Misuse
9.3.1 Fraud, Waste, and Abuse Cases in Pharmacy and Prescription Drug Areas are Driving the Demand for Analytics
9.4 Payment Integrity
9.4.1 Changes in Regulatory Guidelines have Aided the Adoption of Payment Integrity Software
9.5 Other Applications

10 Healthcare Fraud Analytics Market, By End User
10.1 Introduction
10.2 Public & Government Agencies
10.2.1 Public & Government Agencies Dominate the Healthcare Fraud Analytics Market, By End User
10.3 Private Insurance Payers
10.3.1 Private Insurance Payers are Focused on Deploying Analytics to Combat Increasing Monetary Losses
10.4 Third-Party Service Providers
10.4.1 Adoption of Fraud Analytics Solutions By Public Insurers Puts Private Bodies at Risk, Driving Attention Toward Outsourcing
10.5 Employers
10.5.1 Employers are Considering Fraud Analytics Solutions as A Step Toward Better Cost Management

11 Healthcare Fraud Analytics Market, By Region
11.1 Introduction
11.2 North America
11.2.1 US
11.2.1.1 US Dominates the Global Healthcare Fraud Analytics Market
11.2.2 Canada
11.2.2.1 Growing Adoption of Data-Crunching Technologies Like Predictive Analytics to Drive Market Growth
11.3 Europe
11.3.1 Germany
11.3.1.1 Germany is the Fastest-Growing Market for Healthcare Fraud Analytics Solutions in Europe
11.3.2 UK
11.3.2.1 Launch of Initiatives Such as Nhscfa Will Support the Market for Fraud Analytics Solutions in the UK
11.3.3 France
11.3.3.1 Increasing Adoption of Information Technology for the Detection of Healthcare Fraud—A Key Factor Driving Market Growth
11.3.4 Rest of Europe
11.4 Asia Pacific
11.4.1 APAC Market to Witness the Highest Growth in the Healthcare Fraud Analytics Market During the Forecast Period
11.5 Latin America
11.5.1 Volume of Claims Processing is Expected to Increase in Latin American Countries Owing to the Increasing Penetration of Health Insurance
11.6 Middle East & Africa
11.6.1 Healthcare Fraud is One of the Leading Crimes in South Africa

12 Competitive Landscape
12.1 Introduction
12.2 Competitive Situation and Trends
12.2.1 Mergers, Acquisitions, and Joint Ventures
12.2.2 Collaborations, Partnerships, and Agreements
12.2.3 Expansions
12.3 Competitive Leadership Mapping
12.3.1 Visionary Leaders
12.3.2 Innovators
12.3.3 Dynamic Differentiators
12.3.4 Emerging Companies

13 Company Profiles
(Business Overview, Products Offered, Recent Developments, MnM View)*
13.1 IBM
13.2 Optum (A Part of Unitedhealth Group)
13.3 Cotiviti Holdings, Inc.
13.4 Fair Isaac Corporation
13.5 SAS Institute
13.6 Change Healthcare
13.7 EXL Service Holdings, Inc.
13.8 Wipro
13.9 Conduent, Inc.
13.10 HCL Technologies
13.11 CGI Group
13.12 DXC Technology Company
13.13 Northrop Grumman Corporation
13.14 LexisNexis (A Part of Relx Group)
13.15 Pondera Solutions
13.16 Other Players Operating in the Healthcare Fraud Analytics Market
13.16.1 WhiteHatAI
13.16.2 Healthcare Fraud Shield
13.16.3 FraudLens, Inc.
13.16.4 HMS
13.16.5 FraudScope, Inc.

*Business Overview, Products Offered, Recent Developments, MnM View Might Not Be Captured in Case of Unlisted Companies.

14 Appendix
14.1 Discussion Guide
14.2 Knowledge Store: Marketsandmarkets’ Subscription Portal
14.3 Available Customizations
14.4 Related Reports
14.5 Author Details

List of Tables

Table 1 List of Stakeholders Interviewed for the Study
Table 2 Companies Offering Innovative Fraud Analytics Solutions
Table 3 Healthcare Fraud Analytics Market, By Solution Type, 2018–2025 (USD Million)
Table 4 Descriptive Analytics Solutions for Healthcare Fraud Detection
Table 5 Descriptive Analytics Market, By Region, 2018–2025 (USD Million)
Table 6 Descriptive Analytics Market, By Country, 2018–2025 (USD Million)
Table 7 Predictive Analytics Solutions for Healthcare Fraud Detection
Table 8 Predictive Analytics Market, By Region, 2018–2025 (USD Million)
Table 9 Predictive Analytics Market, By Country, 2018–2025 (USD Million)
Table 10 Prescriptive Analytics Solutions for Healthcare Fraud Detection
Table 11 Prescriptive Analytics Market, By Region, 2018–2025 (USD Million)
Table 12 Prescriptive Analytics Market, By Country, 2018–2025 (USD Million)
Table 13 Healthcare Fraud Analytics Market, By Delivery Model, 2018–2025 (USD Million)
Table 14 Key Vendors Offering On-Premise Solutions in the Market
Table 15 Market for On-Premise Delivery Models, By Region, 2018–2025 (USD Million)
Table 16 Market for On-Premise Delivery Models, By Country, 2018–2025 (USD Million)
Table 17 Key Vendors Providing On-Demand Solutions
Table 18 Market for On-Demand Delivery Models, By Region, 2018–2025 (USD Million)
Table 19 Market for On-Demand Delivery Models, By Country, 2018–2025 (USD Million)
Table 20 Market, By Application, 2018–2025 (USD Million)
Table 21 Deployment of Prepayment vs Postpayment Analytics Systems
Table 22 Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 23 Market for Insurance Claims Review, By Region, 2018–2025 (USD Million)
Table 24 Market for Insurance Claims Review, By Country, 2018–2025 (USD Million)
Table 25 Market for Postpayment Claims Review, By Region, 2018–2025 (USD Million)
Table 26 Market for Postpayment Claims Review, By Country, 2018–2025 (USD Million)
Table 27 Market for Prepayment Claims Review, By Region, 2018–2025 (USD Million)
Table 28 Market for Prepayment Claims Review, By Country, 2018–2025 (USD Million)
Table 29 Market for Pharmacy Billing Misuse Applications, By Region, 2018–2025 (USD Million)
Table 30 Market for Pharmacy Billing Misuse Applications, By Country, 2018–2025 (USD Million)
Table 31 Market for Payment Integrity Applications, By Region, 2018–2025 (USD Million)
Table 32 Market for Payment Integrity Applications, By Country, 2018–2025 (USD Million)
Table 33 Healthcare Fraud Analytics Market for Other Applications, By Region, 2018–2025 (USD Million)
Table 34 Market for Other Applications, By Country, 2018–2025 (USD Million)
Table 35 Market, By End User, 2018–2025 (USD Million)
Table 36 Market for Public & Government Agencies, By Region, 2018–2025 (USD Million)
Table 37 Market for Public & Government Agencies, By Country, 2018–2025 (USD Million)
Table 38 Market for Private Insurance Payers, By Region, 2018–2025 (USD Million)
Table 39 Market for Private Insurance Payers, By Country, 2018–2025 (USD Million)
Table 40 Market for Third-Party Service Providers, By Region, 2018–2025 (USD Million)
Table 41 Healthcare Fraud Analytics Market for Third-Party Service Providers, By Country, 2018–2025 (USD Million)
Table 42 Market for Employers, By Region, 2018–2025 (USD Million)
Table 43 Market for Employers, By Country, 2018–2025 (USD Million)
Table 44 Market, By Region, 2018–2025 (USD Million)
Table 45 North America: Market, By Country, 2018–2025 (USD Million)
Table 46 North America: Market, By Delivery Model, 2018–2025 (USD Million)
Table 47 North America: Market, By Solution Type, 2018–2025 (USD Million)
Table 48 North America: Market, By Application, 2018–2025 (USD Million)
Table 49 North America: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 50 North America: Market, By End User, 2018–2025 (USD Million)
Table 51 US: Healthcare Fraud Analytics Market, By Delivery Model, 2018–2025 (USD Million)
Table 52 US: Market, By Solution Type, 2018–2025 (USD Million)
Table 53 US: Market, By Application, 2018–2025 (USD Million)
Table 54 US: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 55 US: Market, By End User, 2018–2025 (USD Million)
Table 56 Canada: Market, By Delivery Model, 2018–2025 (USD Million)
Table 57 Canada: Market, By Solution Type, 2018–2025 (USD Million)
Table 58 Canada: Market, By Application, 2018–2025 (USD Million)
Table 59 Canada: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 60 Canada: Market, By End User, 2018–2025 (USD Million)
Table 61 List of Some of the Ehfcn Member Organization Across Europe
Table 62 Europe: Market, By Country, 2018–2025 (USD Million)
Table 63 Europe: Healthcare Fraud Analytics Market, By Delivery Model, 2018–2025 (USD Million)
Table 64 Europe: Market, By Solution Type, 2018–2025 (USD Million)
Table 65 Europe: Market, By Application, 2018–2025 (USD Million)
Table 66 Europe: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 67 Europe: Market, By End User, 2018–2025 (USD Million)
Table 68 Germany: Market, By Delivery Model, 2018–2025 (USD Million)
Table 69 Germany: Market, By Solution Type, 2018–2025 (USD Million)
Table 70 Germany: Market, By Application, 2018–2025 (USD Million)
Table 71 Germany: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 72 Germany: Market, By End User, 2018–2025 (USD Million)
Table 73 UK: Market, By Delivery Model, 2018–2025 (USD Million)
Table 74 UK: Market, By Solution Type, 2018–2025 (USD Million)
Table 75 UK: Market, By Application, 2018–2025 (USD Million)
Table 76 UK: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 77 UK: Market, By End User, 2018–2025 (USD Million)
Table 78 France: Market, By Delivery Model, 2018–2025 (USD Million)
Table 79 France: Market, By Solution Type, 2018–2025 (USD Million)
Table 80 France: Healthcare Fraud Analytics Market, By Application, 2018–2025 (USD Million)
Table 81 France: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 82 France: Market, By End User, 2018–2025 (USD Million)
Table 83 RoE: Market, By Delivery Model, 2018–2025 (USD Million)
Table 84 RoE: Market, By Solution Type, 2018–2025 (USD Million)
Table 85 RoE: Market, By Application, 2018–2025 (USD Million)
Table 86 RoE: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 87 RoE: Market, By End User, 2018–2025 (USD Million)
Table 88 Asia Pacific: Market, By Delivery Model, 2018–2025 (USD Million)
Table 89 Asia Pacific: Market, By Solution Type, 2018–2025 (USD Million)
Table 90 Asia Pacific: Market, By Application, 2018–2025 (USD Million)
Table 91 Asia Pacific: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 92 Asia Pacific: Market, By End User, 2018–2025 (USD Million)
Table 93 Latin America: Healthcare Fraud Analytics Market, By Delivery Model, 2018–2025 (USD Million)
Table 94 Latin America: Market, By Solution Type, 2018–2025 (USD Million)
Table 95 Latin America: Market, By Application, 2018–2025 (USD Million)
Table 96 Latin America: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 97 Latin America: Market, By End User, 2018–2025 (USD Million)
Table 98 MEA: Market, By Delivery Model, 2018–2025 (USD Million)
Table 99 MEA: Market, By Solution Type, 2018–2025 (USD Million)
Table 100 MEA: Market, By Application, 2018–2025 (USD Million)
Table 101 MEA: Market for Insurance Claims Review, By Type, 2018–2025 (USD Million)
Table 102 MEA: Healthcare Fraud Analytics Market, By End User, 2018–2025 (USD Million)
Table 103 Mergers, Acquisitions, and Joint Ventures: January 2017–December 2019
Table 104 Collaborations, Partnerships, and Agreements: January 2017–December 2019
Table 105 Expansions: January 2017–December 2019

List of Figures

Figure 1 Research Design
Figure 2 Breakdown of Primary Interviews: By Company Type, Designation, and Region
Figure 3 Data Triangulation Methodology
Figure 4 Healthcare Fraud Analytics Market, By Solution Type, 2020 vs 2025 (USD Million)
Figure 5 Market, By Delivery Model, 2020 vs 2025 (USD Million)
Figure 6 Market, By Application, 2020 vs 2025 (USD Million)
Figure 7 Market, By End User, 2020 vs 2025 (USD Million)
Figure 8 Geographical Snapshot of the Market
Figure 9 Large Number of Fraudulent Activities in Healthcare to Drive Market Growth
Figure 10 Descriptive Analytics Segment Accounted for the Largest Share of the APAC Market in 2019
Figure 11 APAC Market to Register the Highest Growth During the Forecast Period
Figure 12 North America Will Continue to Dominate the Market in 2025
Figure 13 Developing Regions to Register Higher Growth During the Forecast Period
Figure 14 Market: Drivers, Restraints, Opportunities, and Challenges
Figure 15 US National Healthcare Fraud and Opioid Takedown Trends
Figure 16 Incidence of Fraudulent Claims—Global Scenario (2017)
Figure 17 Major Mergers and Acquisitions in the Healthcare Fraud Analytics Market
Figure 18 North America: Market Snapshot
Figure 19 Europe: Market Snapshot
Figure 20 Asia Pacific: Market Snapshot
Figure 21 Key Developments in the Analytics Market Between January 2017 and December 2019
Figure 22 Market: Competitive Leadership Mapping, 2019
Figure 23 Company Snapshot: IBM
Figure 24 Company Snapshot: Fair Isaac Corporation
Figure 25 Company Snapshot: EXL Service Holdings, Inc.
Figure 26 Company Snapshot: Wipro Limited
Figure 27 Company Snapshot: Conduent, Inc.
Figure 28 Company Snapshot: HCL Technologies
Figure 29 Company Snapshot: CGI Group
Figure 30 Company Snapshot: DXC Technology Company
Figure 31 Company Snapshot: Northrop Grumman Corporation
Figure 32 Company Snapshot: Relx Group

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