Healthcare Fraud Detection Market to Surge at CAGR of 28.9% : Insurance Claim, Prepay, Post Payment

The Health Fraud Detection Market market
is expected to reach USD 2,242.7
million by 2022 from USD 631.0 million in
2017, at a CAGR of 28.9%

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Factors such as the large number of fraudulent activities in healthcare; increasing number of patients seeking health insurance; the prepayment review model; growing pressure of fraud, waste, and abuse on healthcare spending; and high returns on investment are driving the growth of this market.

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This report segments the healthcare fraud detection market into type, component, delivery model, application, end user, and region:-

Based on type, the market is segmented into descriptive, predictive, and prescriptive analytics. The prescriptive analytics segment is expected grow at the highest CAGR during the forecast period. The ability of prescriptive analytics to ensure the synergistic integration of predictions and prescriptions is the key driver for the prescriptive analytics segment.

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Based on component, the market is segmented into services and software. The services segment is expected to account for the largest share of the healthcare fraud detection market in 2017. With the increasing need for fraud analytics services and the introduction of technologically advanced healthcare fraud detection software, which requires extensive training to use as well as regular upgrades, this segment is expected to grow at the highest CAGR during the forecast period.

Based on delivery model, the market is segmented into on-demand and on-premise models. The on-demand healthcare fraud detection segment is expected to grow at the highest CAGR during the forecast period. The high growth of this segment is attributed to the lack of upfront capital investments for hardware, higher flexibility, pay-as-you-go pricing of this model, and the increased demand for self-driven analytics.

Based on application, the market is segmented into insurance claims review, payment integrity, and other applications. The insurance claims review segment is expected to dominate the healthcare fraud detection market in 2017. This segment is also expected to register the highest growth rate during the forecast period, primarily due to the increasing number of patients seeking health insurance, rising number of fraudulent claims, and growing adoption of the prepayment review model.

Based on end user, the market is segmented into private insurance payers, public/government agencies, employers, and third party service providers. The private insurance payers segment is expected to dominate the market during the forecast period. The need to comply with stringent laws and the opportunity for substantial cost savings are some important factors driving private payers to invest in advanced fraud analytics.

Among the regional segments, North America is expected to grow at the highest CAGR during the forecast period. Growth in this regional segment is mainly driven by the increase in the number of people seeking health insurance, increasing cases of healthcare fraud, favorable government initiatives to combat healthcare fraud, rising pressure to reduce healthcare costs, technological advancements, and greater product and service availability in this region.

The healthcare fraud detection market is highly competitive with the presence of several small and big players. Some of the players in the healthcare fraud detection market are IBM (US), Optum (US), SAS (US), McKesson (US), SCIO (US), Verscend (US), Wipro (India), Conduent (US), HCL (India), CGI (Canada), DXC (US), Northrop Grumman (US), LexisNexis (US), and Pondera (US).

source:  https://www.linkedin.com/pulse/healthcare-fraud-detection-market-surge-cagr-289-insurance-poonam-as

 

Berikut Gambaran Isi Pedoman Pencegahan Kecurangan JKN Terbaru

Komisi Pemberantasan Korupsi (KPK) mewacanakan rencana penindakan pelaku kecurangan (fraud) Jaminan Kesehatan Nasional (JKN) per 2018 ini. Rencana ini menyusul pengamatan KPK yang memandang belum ada upaya optimal pencegahan fraud oleh berbagai stakeholder. Langkah pertama yang dilakukan untuk mendukung rencana ini adalah penyusunan pedoman pencegahan, deteksi, dan penyelesaian kecurangan JKN. Tiga pedoman ini disusun bersama antara Kementerian Kesehatan (Kemenkes) RI, BPJS Kesehatan, dan KPK. Inspektorat Jenderal Kemenkes menjadi koordinator penyusunan pedoman pencegahan. Ketiga pedoman ini disusun sejak pertengahan tahun 2017.

urPedoman Pencegahan Kecurangan JKN memberikan informasi lebih lengkap tentang kecurangan JKN dibanding Permenkes No. 36/2015. Dalam pedoman ini terdapat penambahan jumlah pelaku yang berpotensi melakukan fraud. Penambahan juga terdapat pada bentuk-bentuk potensi fraud yang berpotensi dilakukan berbagai stakeholder. Pedoman ini juga menambahkan contoh-contoh bentuk potensi fraud walaupun tetap mengakomodir perkembangan bentuk fraud di masa mendatang.

Poin inti tentang pencegahan kecurangan JKN tercantum pada bab terakhir dalam pedoman ini. Dalam bab ini disebutkan kerangka kerja pencegahan fraud JKN berupa siklus yaitu sistem pemcegahan kecurangan – implementasi pencegahan kecurangan – pembinaan dan pengawasan – dan kembali ke sistem pencegahan kecurangan. Kerangka kerja ini belum nampak pada Permenkes No. 36/ 2015.

Secara umum pembangunan sistem pencegahan kecurangan dilaksanakan dengan empat prinsip dasar yaitu: penyusunan kebijakan dan pedoman, budaya pencegahan fraud, kendali mutu dan kendali biaya, serta pembentukan tim pencegahan fraud. Bentuk implementasi pencegahan kecurangan mengarah kepada prinsip-prinsip dasar sistem ini. Terdapat contoh bentuk implementasi pencegahan untuk masing-masing stakeholder yang terlibat dalam penyelenggaraan program JKN. Misalnya, bentuk implementasi terkait prinsip penyusunan kebijakan dan pedoman oleh BPJS Kesehatan adalah menyusun kebijakan & pedoman dalam melakukan monitoring dan evaluasi secara rutin terhadap hasil kerja Petugas BPJS Kesehatan. Contoh lainnya: bentuk implementasi terkait prinsip pengembangan pelayanan berorientasi kendali mutu dan kendali biaya di FKRTL adalah melakukan koordinasi dengan TKMKB Teknis dalam pelaksanaan audit klinis dan utilization review.

Tahap pembinaan dan pengawasan juga dilakukan kepada stakeholder oleh Menteri, Gubernur, Bupati/ Walikota serta melibatkan pejabat yang berwenang. Misalnya pembinaan dan pengawasan kepada BPJS Kesehatan melibatkan Dewan Pengawas BPJS Kesehatan, Dewan Jaminan Sosial Nasonal (DJSN), Otoritas Jasa Keuangan (OJK) dan Satuan Pengawasan Intern (SPI) BPJS Kesehatan. Contoh lainnya: pembinaan dan pengawasan kepada FKRTL dapat melibatkan badan pengawas rumah sakit, dewan pengawas rumah sakit, perhimpunan/asosiasi perumahsakitan, dan organisasi profesi.

Saat ini isi pedoman detil memang masih dalam proses pematangan oleh tim penyusun. Tidak menutup kemungkinan akan ada detil yang berubah dari item-item yang sudah tercantum saat ini, meskipun perubahannya tidak akan terlalu jauh. Item yang tercantum dalam pedoman diharapkan memberi gambaran cara melakukan pencegahan fraud dengan mudah dan tidak memberatkan stakeholder.
Anda penasaran isi detilnya? Kita tunggu peluncuran pedoman ini sekira akhir 2018.

Text: Puti Aulia Rahma, drg., MPH, CFE

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