Running in the Never-ending Race Against Healthcare Fraud (Strategic Focus)

Introduction

As healthcare reform takes center stage in the US, fraud is being ecognized as a larger and more complex issue then most realized. In this report, Datamonitor surveys the current healthcare fraud market and examines both near- and long-term changes that will impact technology solutions and healthcare payers.

Scope

*Provides an overview of market trends

*Highlights priorities for solution development

*Analyzes the pricing models of fraud solutions

Highlights

In healthcare fraud prevention, public sector leads the charge

Retrospective, prospective and real-time solutions should be used in tandem

Collaboration between public and private payers is key

Reasons to Purchase

*Understand how the Obama administration is impacting healthcare fraud

*Identify the near and mid-term threats to fraud detection

Report Highlights

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Overview 1
Catalyst 1
Summary 1
Key Messages 2
In healthcare fraud prevention, public sector leads the charge 2
Retrospective, prospective and real-time solutions should be used in tandem 2
Collaboration between public and private payers is key 2
Table of Contents 4
Table of figures 5
Market Opportunity 6
Detecting healthcare fraud is a never-ending 'Red Queen's race' 6
Both private and public payers are now shining a spotlight on healthcare fraud 9
In an economic recession, payers are unable to pass higher costs onto patients 9
Government led initiatives against fraud impact the private sector as well 10
As providers move to EHRs and ICD-10, opportunities for fraud will likely increase 10
Yet tackling healthcare fraud is still a sensitive subject that is not taken seriously 11
Within a payer organization, fraud is a politically difficult topic to broach 11
Payers do not want to alienate their provider networks 11
While committing healthcare fraud may be a laughing matter, fighting fraud is not 12
Technology Evolution 13
Old and new tools are being used to fight fraud 13
Healthcare fraud detection is slowly moving closer to real time 14
Retrospective analysis of claims data will continue to play a role in catching fraud 14
The use of prospective analysis is growing and the benefits are clear 15
Regional health information organizations may increase collaboration between payers 15
On-demand solutions are the easiest and most cost effective 16
Educating doctors on good billing practices is a must 17
Looking to the future, EHRs will change billing processes and, in turn, fraud detection 18
Customer Impact: Recommendations to Healthcare Payers 19
Be open to increased collaboration with other payers 19
Incorporate patient inquiries as a part of the fraud detection process 19
If financially possible, consider using more than one solution 19
Go to Market: Recommendations to Technology Vendors 21
IT vendors need to start focusing on medical identity solutions as well 21
Vendors must take market education to a new level, the C-level 21
It goes without saying, but technology companies should continue developing new tools 22
APPENDIX 23
Abbreviations 23
Methodology 23
Further reading 23
Ask the analyst 24
Datamonitor consulting 24
Disclaimer 24
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List of Tables
List of Figures
Figure 1: The number of stakeholders involved in the claims process makes it vulnerable to fraud 7
Figure 2: Potential for fraud centers around the provider 8
Figure 3: On the surface, claims processing seems to be straightforward 9
Figure 4: A comparison of real-time, prospective and retrospective analysis 15
Figure 5: Claim submission process will be streamlined in the future due to EHRs 18
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