IDC Health Insights Evaluates US Healthcare Payer Fraud, Waste and Abuse

IDC Health InsightsIDC Health Insights new report that describes the distinctive offerings and capabilities from six fraud, waste and abuse (FWA) services providers and the market they compete in. The new study, IDC Marketscape: US Healthcare Payer Fraud, Waste and Abuse Services 2015 Vendor Assessment,” (Document #HI253636) examines in detail the FWA consulting and business process outsourcing (BPO) services.  Vendors evaluated in this report include: Emdeon, IBM, McKesson, Optum, SCIO and Xerox.

Priority for investment in payer fraud, waste and abuse solutions is rising quickly on payer executive agendas because of the accelerated rate of evolution of the payer marketplace in the wake of government-mandated reform. Investment in U.S. healthcare payer FWA solutions (software and services) is rising rapidly in 2014–2015. While already present in over 50% of payers, in the next few years, such solutions will become ubiquitous among payers of all types and sizes in both the commercial and government sectors in some form. In the next three to five years, many payers will continue to enhance their overall FWA defensive capabilities by investing in oftentimes complementary solutions from multiple vendors.

The services component of payer FWA solutions is becoming more and more important, and it is now common for payer FWA software to be delivered to buyers “as a service.” Technology improvements in analytics and software-as-a-service (SaaS) solution delivery have made it more feasible for vendors to provide rapidly scalable, outsourced services at decreasing costs with defensive capabilities that outstrip those available to all but the largest payers.

Because of these developments, payers are therefore seeking guidance on how to invest in the different types of service offerings available and how the major vendors compete with each other. This IDC Health Insights report uses the IDC MarketScape methodology to assess six vendors competing in the U.S. healthcare payer FWA services market. A detailed profile supports the evaluation of the offerings from each of the selected vendors. Each profile outlines a vendor’s offering components, evolution, strengths, and challenges.

“Disruption caused by health insurance exchanges and the adoption of value-based care delivery is coinciding with a long-term rise in non–medical professional, “consumer based” fraud. Payers therefore seek more adaptive, cost-effective counter-fraud defenses,” said Sven Lohse, research manager, IDC Health Insights. “Predictive analytics are evolving rapidly to address that need, and this has led to a new generation of analytics-as-a-service offerings. This IDC MarketScape helps payers quickly and cost-effectively evaluate best-of-breed FWA services.”

IDC MarketScape criteria selection, weightings and vendor scores represent well-researched IDC judgment about the market and specific vendors. IDC analysts tailor the range of standard characteristics by which vendors are measured through structured discussions, surveys, and interviews with market leaders, participants and end users. Market weightings are based on user interviews, buyer surveys and the input of a review board of IDC experts in each market. IDC analysts base individual vendor scores, and ultimately vendor positions within the IDC MarketScape, on detailed surveys and interviews with the vendors, publicly available information and end-user experiences in an effort to provide an accurate and consistent assessment of each vendor’s characteristics, behavior and capability.

IDC MarketScape vendor analysis model is designed to provide an overview of the competitive fitness of IT, telecommunications, or industry-specific suppliers in a given market. The research methodology utilizes a rigorous scoring methodology based on both qualitative and quantitative criteria that results in a single graphical illustration of each vendor’s position within a given market. IDC MarketScape provides a clear framework in which the product and service offerings, capabilities and strategies, and current and future market success factors of IT, telecommunications, or industry-specific vendors can be meaningfully compared. The framework also provides technology buyers with a transparent foundation to allow companies to independently compare the strengths and weaknesses of current and prospective vendors.

IDC Health Insights assists health businesses and IT leaders, as well as the suppliers who serve them, in making more effective technology decisions by providing accurate, timely, and insightful fact-based research and consulting services.

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