In healthcare fraud prevention, public sector leads the charge

Oct 28 2009

MarketResearch.com has announced the addition of Datamonitor's new report, "Running in the Never-ending Race Against Healthcare Fraud (Strategic Focus)," to their collection of Healthcare market reports. For more information, visit> Introduction

As healthcare reform takes center stage in the US, fraud is being recognized as a larger and more complex issue than 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

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