Intelligent Tools to Automate Payer and Provider Functions Will Boost Efficiency and Deliver a Digital Customer Experience
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.
The publisher 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.
Table of Contents
1. Strategic Imperatives
- 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™
2. Growth Opportunity Analysis
- Scope of Analysis
- Voices from the Industry - What Impacts Claims Management Today?
- Definitions of Payer & Provider Electronic Administrative Transaction
- 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
- US Healthcare Claims Management Segmentation by Technology
3. Growth Environment
- Growth Environment for the Claims Management Market
- 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
- Pricing Trends and Forecast Analysis
- Competitive Environment
- Revenue Share
- Revenue Share Analysis
4. Growth Opportunity Analysis - Medical Billing & Coding Segment
- Growth Metrics
- Revenue Forecast
- Forecast Analysis
5. Growth Opportunity Analysis - Claims Administration & Processing Segment
- Growth Metrics
- Revenue Forecast
- Forecast Analysis
6. Growth Opportunity Analysis - Payment Integrity Segment
- Growth Metrics
- Revenue Forecast
- Forecast Analysis
7. Growth Opportunity Analysis - BPA Segment
- Growth Metrics
- Revenue Forecast
- Forecast Analysis
8. Growth Opportunity Universe
- Growth Opportunity 1 - Payer Integration of Digital Claims Functions
- Growth Opportunity 2 - Blockchain Technology for Smart Contracts
- Growth Opportunity 3 - RPA for Intelligent Payer Automation
- Growth Opportunity 4 - AI in Prior-Authorization (PA) Automation and Triaging
9. Next Steps
- Your Next Steps
- Why Frost, Why Now?
- List of Exhibits
- Legal Disclaimer
