China Healthcare Claim Management Market Overview, 2030

China's healthcare system is a mix of public and private providers. The government has been progressively expanding public health insurance under programs like the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Rural Cooperative Medical Scheme (NRCMS), covering the vast majority of citizens. The private healthcare sector is growing, especially in cities, but private insurance companies mainly supplement public insurance, providing higher-tier services and coverage for specialized treatments that public plans may not cover. Private insurance policies in China are generally negotiable in terms of premiums and coverage, though they depend on individual health conditions, age, and risk assessments. Health insurance policies are typically available for individuals between the ages of 18 and 60, though some companies may offer coverage for those over 60 for an additional premium. Those with pre-existing conditions or disabilities may face higher premiums or may be excluded from certain benefits, although some companies may still offer policies with specific terms. The Personal Information Protection Law (PIPL), which came into effect in 2021, sets out rules governing how patient data should be collected, stored, and shared. Health coverage for diseases in China largely focuses on essential services and common conditions, but chronic and specialized treatments, as well as certain medications, might not always be covered fully by public insurance. The claims process in China can be cumbersome, as individuals often have to navigate both public and private systems.

According to the research report ""China Healthcare Claim Management Market Overview, 2030,"" published by Bonafide Research, the China Healthcare Claim Management market is anticipated to grow at more than 16.67% CAGR from 2025 to 2030. China’s healthcare claim management market is expanding rapidly, driven by the country’s evolving insurance landscape and government healthcare reforms. Notable players include Ping An Insurance, China Life Insurance, and ZhongAn Insurance, alongside third-party administrators (TPAs) like Wells Fargo Insurance and Ant Financial. The market is expanding due to the rising penetration of health insurance, both public and private, and the government’s increasing push for universal healthcare. The increasing volume of health claims, spurred by government programs like the Basic Medical Insurance (BMI) and private health insurance plans, is driving the need for more sophisticated claim management systems. The sheer scale of the population and the increasing complexity of claims have made fraud detection a significant issue. Insurers must address fraudulent claims, which can range from inflated medical expenses to fake treatments, by adopting advanced technologies such as machine learning algorithms and data analytics to spot patterns and prevent fraudulent activities. Denial management is another challenge, as insurance companies and healthcare providers face difficulties in accurately assessing claims, especially with varying levels of care and the use of multiple private and public health schemes. This often leads to disputes over denied claims, further complicating the claim management process. These technologies are enhancing the customer experience by providing real-time updates and reducing the need for physical documentation. The Chinese government is also working on improving the regulatory framework governing healthcare claims management.

In the Chinese healthcare claims market, Medical billing in China is an integral part of the healthcare reimbursement process, especially as the country continues to expand its social health insurance system. The majority of healthcare claims in China are processed through public insurance programs, including the Basic Medical Insurance (BMI) scheme, which covers urban employees, rural residents, and special groups. For healthcare providers, accurate billing is essential to ensure that claims are processed and reimbursed in compliance with government policies. Providers including hospitals and clinics must navigate a complex set of rules for coding and billing across different regions and insurance schemes. The adoption of electronic medical billing systems has increased, allowing healthcare providers to efficiently submit claims and avoid errors in coding or submission, which can lead to delays in reimbursement. Claims processing in China is overseen primarily by public insurance schemes, such as the BMI, and private insurers, covering a growing population that seeks private healthcare options. Claims processing involves the verification of eligibility, adjudication of services rendered, and determining reimbursement levels, which are influenced by the type of insurance and local healthcare policies. The government has been investing heavily in digital health infrastructure, creating a more efficient claims processing environment with a focus on automation and data integration. Advanced technologies, such as AI and blockchain, are being integrated into claims processing systems to improve accuracy, reduce fraud, and speed up reimbursement timelines.

In the Chinese healthcare claims market, Software solutions are at the heart of modernizing China’s healthcare claims market. As the country continues to expand its public health insurance system, including the Basic Medical Insurance (BMI) programs, the need for efficient and automated claims management has grown. Healthcare providers, such as hospitals and clinics, rely on specialized software for medical billing, claims submission, and coding compliance. With the Chinese healthcare system becoming more digitized, many healthcare providers now use Electronic Health Record (EHR) systems integrated with claims management platforms. These software solutions help providers submit claims accurately, comply with national and regional regulations, and reduce errors in billing codes. Software that facilitates interoperability between different provincial systems and public insurance programs is vital in ensuring a seamless flow of data, enhancing the claims processing speed and reducing administrative costs. The integration of AI and data analytics within claims management software also supports fraud detection and optimizes reimbursement rates, which is increasingly important as the government encourages digital health innovation. Services in China’s healthcare claims market are equally essential, providing support functions to both payers and providers. Medical billing services are often outsourced to third-party providers to ensure claims are submitted correctly and in compliance with regional rules and insurance policies. These services help healthcare providers navigate the complex claims landscape, reducing administrative burdens and accelerating reimbursement times. Third-party administrators (TPAs) are responsible for managing and processing claims on behalf of insurers. TPAs handle everything from verifying eligibility to adjudicating claims and managing disputes, thus improving the efficiency of claims processing for both public and private insurers.

In the Chinese healthcare claims market, various end users, including healthcare payers, healthcare providers, and other stakeholders, play key roles in the claims process, each contributing to the overall efficiency and functionality of the system. Healthcare payers in China are primarily government programs, such as the Basic Medical Insurance (BMI) system, which covers employees, rural residents, and special groups, as well as private health insurance providers, that cater to individuals seeking additional coverage. The government’s role is significant, as public insurance schemes are the primary funding source for healthcare, and payers use advanced claims processing systems to verify eligibility, process claims, and reimburse healthcare providers. These providers must ensure claims are submitted accurately and comply with the various billing codes and regulations associated with both public and private insurance systems. Providers often rely on medical billing software to ensure their claims are compliant with national standards, provincial requirements, and the specific insurance provider's guidelines. Given the complexity of the Chinese healthcare system, providers also often rely on third-party administrators (TPAs) to manage claims processing and navigate the intricacies of the public-private healthcare landscape. Other end users include patients, third-party administrators (TPAs), and healthcare consultants. Patients in China play a role in ensuring their eligibility for coverage and helping with the documentation required for claims processing, particularly when utilizing private health insurance. TPAs are critical in managing claims on behalf of payers, assisting with adjudication, and resolving disputes. Healthcare consultants provide expertise to insurers and providers, offering advice on optimizing claims management processes, navigating regulatory changes, and ensuring compliance with evolving healthcare policies.

Considered in this report
• Historic Year: 2019
• Base year: 2024
• Estimated year: 2025
• Forecast year: 2030

Aspects covered in this report
• Healthcare Claims Processing Market with its value and forecast along with its segments
• Various drivers and challenges
• On-going trends and developments
• Top profiled companies
• Strategic recommendation

By Product
• Medical Billing
• Claims Processing

By Component
• Software
• Services

By End User
• Healthcare Payers
• Healthcare Providers
• Other End Users

The approach of the report:
This report consists of a combined approach of primary as well as secondary research. Initially, secondary research was used to get an understanding of the market and listing out the companies that are present in the market. The secondary research consists of third-party sources such as press releases, annual report of companies, analyzing the government generated reports and databases. After gathering the data from secondary sources primary research was conducted by making telephonic interviews with the leading players about how the market is functioning and then conducted trade calls with dealers and distributors of the market. Post this we have started doing primary calls to consumers by equally segmenting consumers in regional aspects, tier aspects, age group, and gender. Once we have primary data with us we have started verifying the details obtained from secondary sources.

Intended audience
This report can be useful to industry consultants, manufacturers, suppliers, associations & organizations related to agriculture industry, government bodies and other stakeholders to align their market-centric strategies. In addition to marketing & presentations, it will also increase competitive knowledge about the industry.