헬스케어 부정 탐지 시장 : 컴포넌트, 배포, 용도, 최종사용자, 부정 유형별 - 세계 예측(2025-2032년)

The Healthcare Fraud Detection Market is projected to grow by USD 10.47 billion at a CAGR of 21.34% by 2032.

Strategic orientation to combat healthcare fraud through aligned teams, technology modernization, and pragmatic risk-focused investments

Healthcare fraud detection sits at the intersection of patient safety, payer integrity, and regulatory compliance, and executives must appreciate both the scale of the challenge and the evolving tools available to address it. Fraud manifests across billing, claims, enrollment, and prescription channels, straining operational budgets and eroding trust across provider, payer, and pharmacy networks. To respond effectively, organizations need a clear orientation to the drivers of fraudulent activity, the limitations of legacy controls, and the potential of modern detection and prevention platforms.

In the current environment, leadership must align cross-functional teams-clinical operations, revenue cycle, compliance, IT, and vendor management-around a common fraud risk taxonomy and measurable objectives. Transitioning from fragmented, rule-centric approaches to integrated analytics and real-time intervention requires both cultural change and investment in modular technologies that can be phased in without disrupting care delivery. Importantly, strategic decisions should be informed by an understanding of component choices across services and software, deployment models, application priorities, end-user dynamics, and fraud typologies so that investments map directly to the highest-value use cases. By framing a coherent fraud detection strategy at the outset, organizations can prioritize pragmatic steps that reduce exposure while building capabilities for continuous improvement.

How analytics advancement, evolving fraud schemes, and stricter regulatory expectations are redefining how organizations detect and prevent healthcare fraud

The fraud detection landscape is undergoing transformative shifts driven by advances in analytics, changes in fraudster behavior, and a growing regulatory focus on program integrity. Machine learning models and behavior-based detection are moving beyond simple pattern matching to incorporate contextual signals such as provider practice patterns, longitudinal patient histories, and cross-channel anomalies. Concurrently, prevention techniques have migrated toward real-time monitoring and automated rule enforcement, allowing organizations to interdict suspicious transactions before downstream costs accrue.

Regulatory developments are recalibrating compliance expectations, prompting payers and providers to enhance transparency, audit readiness, and data governance. As fraud schemes become more sophisticated and distributed, the emphasis on cross-entity data sharing and secure integration is intensifying. This transition elevates the importance of modular services including consulting, integration, and support and maintenance that can help organizations operationalize analytics and detection capabilities. Moreover, cloud-native deployments are enabling scalable analytics compute while on-premise options remain relevant for organizations with strict data residency or latency constraints. Taken together, these forces are creating a competitive environment where agility, data quality, and integrated governance determine effectiveness in preventing and detecting fraud.

Assessing how tariff-induced procurement pressures are reshaping vendor economics, deployment choices, and implementation timelines for fraud detection programs

In 2025, cumulative tariff policies within the United States are introducing new operational cost vectors and supply chain complexities that affect technology procurement, vendor economics, and implementation timelines. Hardware-dependent solutions, such as dedicated on-premise appliances and certain secure compute nodes, are more likely to experience increased procurement costs and longer lead times. These pressures can influence the tradeoffs between on-premise and cloud deployment models, accelerating cloud adoption for organizations seeking to minimize capital expenditures and logistical delays.

At the same time, tariff-driven price movements are prompting vendors to reassess their global sourcing and component strategies, which may lead to altered commercial terms, extended delivery windows for licenses bundled with hardware, and the emergence of subscription models that internalize hardware cost volatility. For buyers, the practical effect is the need to renegotiate vendor agreements with attention to total cost of ownership, service-level commitments, and contingency provisions. From an implementation perspective, project managers should anticipate potential delays and validate vendor supply chains. Ultimately, these tariff-related dynamics increase the importance of modular software architectures, cloud-native services, and flexible support arrangements that reduce exposure to cross-border supply disruptions and cost escalation.

Detailed segmentation intelligence connecting components, deployment models, application priorities, end-user needs, and fraud typologies to inform investment and implementation choices

Segmentation insights reveal where capabilities and organizational priorities intersect, guiding investment and deployment decisions at a granular level. When viewed through the component lens, organizations must weigh Services and Software choices: Services include consulting to define use cases, integration across data and systems to unify disparate sources, and support and maintenance to sustain operational performance; Integration itself divides into data integration to harmonize payloads and system integration to embed detection into existing workflows. On the software side, analytics capabilities span descriptive functions that illuminate historical patterns and predictive engines that identify emerging risk. Detection modules leverage both behavior analysis to surface abnormal practice patterns and pattern matching to detect repeatable anomalies. Prevention is evolving beyond static rule sets into real-time monitoring that flags transactions immediately and rule-based filtering that enforces known constraints.

Deployment considerations remain critical, as cloud approaches provide elasticity for compute-intensive analytics while on-premise installations serve organizations prioritizing control and data residency. Application-level segmentation underscores the diversity of use cases, encompassing billing oversight, claims management workflows, enrollment fraud checks, and prescription-level monitoring to detect pharmaceutical misuse or diversion. End-user distinctions influence procurement and operational design: hospitals and health systems, whether private or public, require integration with clinical systems and revenue cycles; payers, both government and private, emphasize claims adjudication efficiency and audit readiness; pharmacies, split between online and retail channels, prioritize prescription validation and dispensing integrity. Finally, fraud type segmentation drives analytical focus-billing fraud demands precise rules and claim-level anomaly detection, identity theft prioritizes identity resolution and enrollment validation, insurance fraud requires longitudinal pattern discovery, and pharmaceutical fraud necessitates prescription monitoring and supply chain visibility. These segmentation dimensions collectively guide technology selection, implementation sequencing, and resourcing decisions to align capability delivery with risk priorities.

How regional regulatory frameworks, operational practices, and technology maturity across the Americas, EMEA, and Asia-Pacific influence fraud detection priorities and deployments

Regional dynamics materially shape the operational, regulatory, and competitive context for fraud detection solutions. In the Americas, regulatory scrutiny and payer-driven integrity programs are strong drivers of adoption, with stakeholders prioritizing interoperability with electronic data interchange formats and integration with regional billing standards. Transitioning to broader analytics platforms, organizations in this region often pursue cloud-first strategies while maintaining hybrid architectures to balance sovereignty and performance needs.

Europe, Middle East & Africa presents a heterogeneous environment where data protection frameworks, national health system structures, and varied procurement practices affect adoption patterns. Organizations in this region place particular emphasis on privacy-preserving analytics, robust data governance, and vendor compliance with region-specific regulations. Integration work often focuses on harmonizing disparate clinical and claims sources across multi-jurisdictional operations.

Asia-Pacific is characterized by rapid digital transformation and rising investment in health technologies, coupled with diverse regulatory regimes and varying levels of legacy system maturity. In many jurisdictions, the growth of online pharmacy channels and digital enrollment platforms introduces new fraud vectors that detection programs must address. Across these regions, successful deployments reconcile local operational norms with scalable architectures that can be extended across geographies while respecting data sovereignty and legal constraints.

Evaluation of vendor capabilities and partner strategies that combine modular analytics, strong integration toolsets, and governance to sustain fraud detection effectiveness

Company strategies and vendor capabilities are central to how fraud detection functionality is delivered and sustained. Leading providers are differentiating through modular software that combines descriptive and predictive analytics, detection engines that fuse behavior analysis with pattern recognition, and prevention stacks emphasizing real-time monitoring. Vendors that offer robust integration toolkits make it simpler for organizations to connect clinical, billing, and pharmacy systems without protracted custom engineering. Equally important, service partners offering consulting, system integration across data and systems, and long-term support contracts enable clients to operationalize models and maintain model performance over time.

Commercial differentiation also arises from deployment flexibility. Vendors supporting hybrid cloud models and clear migration paths enable organizations with strict compliance or latency requirements to modernize incrementally. Moreover, firms that demonstrate rigorous governance around model explainability, bias mitigation, and audit trails tend to gain traction with payers and regulators alike. From a procurement perspective, buyers are increasingly evaluating vendors on their supply chain resilience and their ability to offer subscription-based pricing that aligns incentives for continuous improvement. Consequently, organizations should prioritize partners whose roadmaps emphasize interoperability, strong integration capabilities, and sustained professional services to bridge analytics research and operational execution.

High-impact strategic actions for leaders to align governance, phased technology adoption, vendor contracts, and operational learning to reduce fraud exposure swiftly

Executive teams should pursue a set of pragmatic, high-impact actions to strengthen fraud defenses while balancing cost and operational disruption. First, establish an enterprise-level fraud risk taxonomy that aligns stakeholders across clinical, revenue cycle, compliance, and IT domains to ensure consistent measurement and prioritization. Next, adopt a phased technology strategy that begins with high-value applications such as billing and claims management, layering in enrollment and prescription monitoring as data maturity improves. During this phased approach, ensure that services investments-consulting, integration, and support and maintenance-are contracted to accelerate deployment and institutionalize operational processes.

Further, favor solutions that enable both descriptive analysis for investigative work and predictive models for proactive interdiction, and insist on detection modules that pair behavior analysis with pattern matching for comprehensive coverage. Consider hybrid deployment models to balance the scalability of cloud platforms with the control of on-premise systems where required. Strengthen vendor agreements by negotiating clear SLAs, contingency clauses for supply chain disruptions, and provisions for explainability and model governance. Finally, invest in cross-functional training and a feedback loop between analysts and modelers to continually refine detection rules and model parameters, thereby converting insights into enduring risk reduction.

Description of a triangulated research methodology combining executive interviews, vendor technical assessment, and synthesis of regulatory and implementation evidence

This research integrates primary qualitative interviews with senior risk and compliance leaders, technical assessments of vendor offerings, and rigorous secondary analysis of publicly available regulatory guidance, academic literature, and industry implementation case studies. The methodology prioritizes triangulation: vendor claims are validated against implementation evidence, model capabilities are assessed through architecture reviews and customer references, and regional regulatory implications are synthesized from official guidance and legal frameworks. Special attention is paid to data integration patterns, model explainability practices, and the operationalization of real-time monitoring to ensure findings are grounded in practical deployment realities.

Analytical rigor is maintained through structured evaluation criteria that assess components across services and software, deployment models, application domains, end-user requirements, and fraud typologies. Where possible, comparative assessments highlight tradeoffs between on-premise and cloud deployments, the incremental value of predictive analytics relative to descriptive reporting, and the role of integration services in reducing time-to-value. Throughout, confidentiality constraints and vendor-provided limitations are acknowledged, and conclusions emphasize replicable best practices rather than proprietary performance metrics.

Concluding synthesis emphasizing the need for modular capabilities, disciplined governance, and continuous operational analytics to transition from reactive detection to proactive prevention

Healthcare fraud detection requires sustained attention, iterative improvement, and alignment between strategy and execution. The evolving landscape-shaped by analytic innovation, changing fraud patterns, and regulatory shifts-demands that organizations adopt flexible, modular approaches to technology and governance. By integrating services and software capabilities, selecting appropriate deployment models, and prioritizing high-impact applications such as billing and claims management, stakeholders can build resilient programs that reduce financial leakage and improve audit readiness.

Leadership must remain vigilant to external factors such as procurement disruptions and regional regulatory divergence, and must continuously calibrate vendor relationships, data integration approaches, and model governance practices. When these elements are combined with a strong feedback loop between operations and analytics, organizations can transition from reactive investigations to proactive prevention. The net effect is an enterprise posture that preserves trust, supports compliance, and enables more efficient allocation of resources to the highest-risk areas.

Table of Contents

1. Preface

• 1.1. Objectives of the Study
• 1.2. Market Segmentation & Coverage
• 1.3. Years Considered for the Study
• 1.4. Currency & Pricing
• 1.5. Language
• 1.6. Stakeholders

2. Research Methodology

3. Executive Summary

4. Market Overview

5. Market Insights

• 5.1. Integration of AI-driven predictive analytics for real-time claims fraud detection and prevention
• 5.2. Adoption of blockchain-based secure data exchange networks to enhance claims transparency and safeguard patient records
• 5.3. Deployment of behavioral analytics to identify unusual provider billing patterns and detect sophisticated fraudulent schemes
• 5.4. Use of natural language processing to analyze unstructured clinical notes and uncover hidden fraud indicators
• 5.5. Cross-industry collaboration through information sharing platforms to strengthen anti fraud intelligence networks
• 5.6. Implementation of advanced anomaly detection algorithms to catch split billing and overutilization in real time
• 5.7. Escalation of telemedicine related fraud driving demand for digital identity verification and monitoring solutions

6. Cumulative Impact of United States Tariffs 2025

7. Cumulative Impact of Artificial Intelligence 2025

8. Healthcare Fraud Detection Market, by Component

• 8.1. Services
  • 8.1.1. Consulting
  • 8.1.2. Integration
    • 8.1.2.1. Data Integration
    • 8.1.2.2. System Integration
  • 8.1.3. Support & Maintenance
• 8.2. Software
  • 8.2.1. Analytics
    • 8.2.1.1. Descriptive Analytics
    • 8.2.1.2. Predictive Analytics
  • 8.2.2. Detection
    • 8.2.2.1. Behavior Analysis
    • 8.2.2.2. Pattern Matching
  • 8.2.3. Prevention
    • 8.2.3.1. Real-time Monitoring
    • 8.2.3.2. Rule-based Filtering

9. Healthcare Fraud Detection Market, by Deployment

• 9.1. Cloud
• 9.2. On Premise

10. Healthcare Fraud Detection Market, by Application

• 10.1. Billing
• 10.2. Claims Management
• 10.3. Enrollment Fraud
• 10.4. Prescription Fraud

11. Healthcare Fraud Detection Market, by End User

• 11.1. Hospitals
  • 11.1.1. Private Hospitals
  • 11.1.2. Public Hospitals
• 11.2. Payers
  • 11.2.1. Government Payers
  • 11.2.2. Private Payers
• 11.3. Pharmacies
  • 11.3.1. Online
  • 11.3.2. Retail

12. Healthcare Fraud Detection Market, by Fraud Type

• 12.1. Billing Fraud
• 12.2. Identity Theft
• 12.3. Insurance Fraud
• 12.4. Pharmaceutical Fraud

13. Healthcare Fraud Detection Market, by Region

• 13.1. Americas
  • 13.1.1. North America
  • 13.1.2. Latin America
• 13.2. Europe, Middle East & Africa
  • 13.2.1. Europe
  • 13.2.2. Middle East
  • 13.2.3. Africa
• 13.3. Asia-Pacific

14. Healthcare Fraud Detection Market, by Group

• 14.1. ASEAN
• 14.2. GCC
• 14.3. European Union
• 14.4. BRICS
• 14.5. G7
• 14.6. NATO

15. Healthcare Fraud Detection Market, by Country

• 15.1. United States
• 15.2. Canada
• 15.3. Mexico
• 15.4. Brazil
• 15.5. United Kingdom
• 15.6. Germany
• 15.7. France
• 15.8. Russia
• 15.9. Italy
• 15.10. Spain
• 15.11. China
• 15.12. India
• 15.13. Japan
• 15.14. Australia
• 15.15. South Korea

16. Competitive Landscape

• 16.1. Market Share Analysis, 2024
• 16.2. FPNV Positioning Matrix, 2024
• 16.3. Competitive Analysis
  • 16.3.1. SAS Institute Inc.
  • 16.3.2. IBM Corporation
  • 16.3.3. Optum, Inc.
  • 16.3.4. Cotiviti, Inc.
  • 16.3.5. Fair Isaac Corporation
  • 16.3.6. Pegasystems Inc.
  • 16.3.7. Verisk Analytics, Inc.
  • 16.3.8. DXC Technology Company
  • 16.3.9. NICE Ltd.
  • 16.3.10. LexisNexis Risk Solutions Inc.