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市場調査レポート
医療不正対策：果てしない戦い
Running in the Never-ending Race Against Healthcare Fraud (Strategic Focus)
| 発行 |
Datamonitor |
| 出版日 |
2009年09月 |
商品コード |
100184 |
| ページ情報 |
英文 25 pages |
| 価格 |
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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
Table of Contents
OVERVIEW
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
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