US Healthcare Claims Management Growth Opportunities

US Healthcare Claims Management Growth Opportunities

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.