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

리서치사	Datamonitor
발행일	2009년 09월	상품코드	100184
페이지 정보	25 pages
가격	US $ 3,395 ￦ 4,045,100 PDF by E-mail (Single User License) US $ 8,488 ￦ 10,113,400 PDF by E-mail (Global Site License)

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Abstract

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 of this research

Provides an overview of market trends
Highlights priorities for solution development
Analyzes the pricing models of fraud solutions

Research and analysis 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

Key reasons to purchase this research

Understand how the Obama administration is impacting healthcare fraud
Identify the near and mid-term threats to fraud detection

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

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

FIGURES

Figure: The number of stakeholders involved in the claims process makes it vulnerable to fraud
Figure: Potential for fraud centers around the provider
Figure: On the surface, claims processing seems to be straightforward
Figure: A comparison of real-time, prospective and retrospective analysis
Figure: Claim submission process will be streamlined in the future due to EHRs