US Healthcare Claims Management Growth Opportunities

US Healthcare Claims Management Growth Opportunities

Intelligent Tools to Automate Payer and Provider Functions Will Boost Efficiency and Deliver a Digital Customer Experience

RELEASE DATE
24-Jan-2023
REGION
North America
Research Code: K7EB-01-00-00-00
SKU: HC03635-NA-MT_27421
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Description

The healthcare claims management industry is evolving. Changes include a shifting reimbursement landscape (for virtual care, urgent care, telehealth, and at-home care); a transition to new, value-based care models (e.g., population-based reimbursement and partial and full capitation payment); and disruption from big tech companies, big-box retailers, and big telecom operators entering the primary care and platform play in healthcare domains.

In addition, health consumer empowerment (self-quantified consumers), employer push for greater value in patient care, and regulatory changes are forcing health insurance companies and providers to redesign their claims processes and capabilities by integrating technologies such as robotic process automation (RPA) and artificial intelligence (AI) in claims predictions, prior-authorization, pre/post-adjudication, and payment.

This study offers qualitative and quantitative analysis of select healthcare claims management software, services, and technology interventions for the US market. It also includes in-depth coverage of key vendors’ solutions and services across payer and provider back-office operations including claims intake, preparation, pre/post-adjudication, claims adjustment, and payment. These solutions and services cover RPA, AI, clearinghouse, payment integrity, care management, revenue cycle management, and electronic medical record/electronic health record (EMR/EHR) across the provider and payer claims’ value chain.

Frost & Sullivan expects the healthcare claims management market to hit $23.81 billion by 2026, increasing at a compound annual growth of 11% (2021 to 2026).

The main growth factors include the rising cost and complexity of claims processes, support for value-based reimbursement models, increasing fraud, waste, and abuse (FWA) in the claims pre- and post-adjudication process, overwhelming administrative and operational costs, and consumer demand for a digital experience.

To keep ahead of their competitors, health insurance incumbents must have a robust process to integrate digital technologies into their core operations to become customer-centric, digitally enabled organizations fit to excel in three foundational areas of claims: customer experience, efficiency, and effectiveness.

Author: Rishi Pathak

RESEARCH: INFOGRAPHIC

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Table of Contents

Why is it Increasingly Difficult to Grow?

The Strategic Imperative 8™

The Impact of the Top 3 Strategic Imperatives on the US Healthcare Claims Management Industry

Growth Opportunities Fuel the Growth Pipeline Engine™

Scope of Analysis

Voices from the Industry—What Impacts Claims Management Today?

Voices from the Industry—What Impacts Claims Management Today?(continued)

Definitions of Payer & Provider Electronic Administrative Transaction

Definitions of Payer & Provider Electronic Administrative Transaction (continued)

US Healthcare Claims Management—Recent Announcements by Centers for Medicare & Medicaid Services (CMS)

Market Share by Revenue of Top US Health Insurance Companies

US Healthcare Payer Authority

Segmentation

Segmentation (continued)

US Healthcare Claims Management Segmentation by Technology

Growth Environment for the Claims Management Market

Growth Environment for the Claims Management Market (continued)

Payer and Provider Claims Administrative Workflow

Evolving Value Propositions of Key Claims Capabilities

US Healthcare Payer Function Components

US Healthcare Payer Back-office Function Components

US Healthcare Payer Claims Processing, Key Challenges

US Healthcare Payer Top Challenges

Payers’ Approach to Multi-faceted Intelligent Operations

Key Trends Driving Payers’ Next-gen Claims Management Capabilities

Trend 1—Real-time Claims Processing in Health Insurance

Trend 2—Emerging Payment Integrity Paradigm

Trend 3—Payer–Provider Collaboration

Trend 4—Cognitive Digital Automation

Key Competitors in the US Healthcare Claims Management Market

Growth Metrics

Growth Drivers

Growth Restraints

Forecast Assumptions

Revenue Forecast

Revenue Forecast by Product

Revenue Forecast Analysis

Revenue Forecast Analysis (continued)

Pricing Trends and Forecast Analysis

Competitive Environment

Revenue Share

Revenue Share Analysis

Growth Metrics

Revenue Forecast

Forecast Analysis

Growth Metrics

Revenue Forecast

Forecast Analysis

Growth Metrics

Revenue Forecast

Forecast Analysis

Growth Metrics

Revenue Forecast

Forecast Analysis

Growth Opportunity 1—Payer Integration of Digital Claims Functions

Growth Opportunity 1—Payer Integration of Digital Claims Functions (continued)

Growth Opportunity 2—Blockchain Technology for Smart Contracts

Growth Opportunity 2—Blockchain Technology for Smart Contracts (continued)

Growth Opportunity 3—RPA for Intelligent Payer Automation

Growth Opportunity 3—RPA for Intelligent Payer Automation (continued)

Growth Opportunity 4—AI in Prior-Authorization (PA) Automation and Triaging

Growth Opportunity 4—AI in Prior-Authorization (PA) Automation and Triaging (continued)

Your Next Steps

Why Frost, Why Now?

List of Exhibits

List of Exhibits (continued)

Legal Disclaimer

The healthcare claims management industry is evolving. Changes include a shifting reimbursement landscape (for virtual care, urgent care, telehealth, and at-home care); a transition to new, value-based care models (e.g., population-based reimbursement and partial and full capitation payment); and disruption from big tech companies, big-box retailers, and big telecom operators entering the primary care and platform play in healthcare domains. In addition, health consumer empowerment (self-quantified consumers), employer push for greater value in patient care, and regulatory changes are forcing health insurance companies and providers to redesign their claims processes and capabilities by integrating technologies such as robotic process automation (RPA) and artificial intelligence (AI) in claims predictions, prior-authorization, pre/post-adjudication, and payment. This study offers qualitative and quantitative analysis of select healthcare claims management software, services, and technology interventions for the US market. It also includes in-depth coverage of key vendors’ solutions and services across payer and provider back-office operations including claims intake, preparation, pre/post-adjudication, claims adjustment, and payment. These solutions and services cover RPA, AI, clearinghouse, payment integrity, care management, revenue cycle management, and electronic medical record/electronic health record (EMR/EHR) across the provider and payer claims’ value chain. Frost & Sullivan expects the healthcare claims management market to hit $23.81 billion by 2026, increasing at a compound annual growth of 11% (2021 to 2026). The main growth factors include the rising cost and complexity of claims processes, support for value-based reimbursement models, increasing fraud, waste, and abuse (FWA) in the claims pre- and post-adjudication process, overwhelming administrative and operational costs, and consumer demand for a digital experience. To keep ahead of their competitors, health insurance incumbents must have a robust process to integrate digital technologies into their core operations to become customer-centric, digitally enabled organizations fit to excel in three foundational areas of claims: customer experience, efficiency, and effectiveness. Author: Rishi Pathak
More Information
Author Dr. Rishi Pathak
Industries Healthcare
No Index No
Is Prebook No
Keyword 1 Healthcare Claims Management Market
Keyword 2 Healthcare Claims Management Software
Keyword 3 Health Claims Management
Podcast No
WIP Number K7EB-01-00-00-00