Running in the Never-ending Race Against Healthcare Fraud (Strategic Focus)
Datamonitor
September 4, 2009 25 Pages - SKU: DFMN2436373
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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
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- 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
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