Improving Efficiencies through the Development of Claims Processing in Healthcare (Strategic Focus)

This publication has been discontinued on July 19, 2011.

Introduction

Abstract

Overview

Introduction

In challenging market conditions that healthcare payers are faced with this report analyzes the claims processing market for healthcare payers. The report looks at how claims processing can bring an increased return on investment (ROI) to payers and what strategy should be taken in order to achieve successful adoption.

Scope

• The evolution of healthcare is creating a challenging environment for healthcare insurers
• Consolidation within the industry creates tough technological decisions for insurers
• The varied structure of healthcare across the markets creates a challenging environment
• Vendors with flexible offerings to healthcare payers will achieve the most success

Report Highlights

This report looks at the drivers and inhibitors behind claims processing for healthcare payers. It analyzes the strategy healthcare payers need to adopt in order to maximize their success.

Reasons to Purchase

• Understanding the challenges facing healthcare payers and how these effect their purchases on claims processing.
• View market sizing for US, UK, Germany, France and Australia from 2007-2013

Table of Contents

• Overview
  • Catalyst
  • Summary
• Key Messages
  • The evolution of healthcare is creating a challenging environment for healthcare insurers
  • Consolidation within the industry creates tough technological decisions for insurers
  • The varied structure of healthcare across the markets creates a challenging environment
  • Vendors with flexible offerings to healthcare payers will achieve the most success
• Table of Contents
• Table of figures
• Market Opportunity
  • Electronic claims processing is coming to play an increasingly prominent role in healthcare
  • There are multiple drivers pushing healthcare payers to adopt claims processing software
    • The rising cost of healthcare is causing considerable pain points for healthcare payers
    • The increasingly consumerist nature of healthcare is forcing payers to become more competitive
    • The cooling of the global economy will make health insurance more competitive
    • Payers' need to adapt to changing circumstances is driving claims processing adoption
    • Claims processing software enables payers to manage government regulations more easily
    • The continual need to reduce fraud and errors is driving the adoption of claims processing software
  • The culture of healthcare payers is inhibiting the take up of claims processing
    • The fragmented nature of healthcare payers makes claims processing implementations challenging
    • The short term vision of mid-sized healthcare payers is inhibiting progression in claims processing
    • The conservatism of healthcare insurers is limiting their investment in claims processing automation
  • While the US remains the dominant market - other areas offer opportunities for vendors
    • The US is by far the most dominant market for claims processing software
    • While a small market, the UK offers opportunities for vendors to implement claims processing software
    • With its mix of public and private Australia has a need for electronic claims processing
    • Germany and France, while challenging markets, offer opportunities for vendors
• Customer Impact: Making the right choices
  • The technical advances in claims processing are helping to increase its ROI
    • The automation of claims processing should become standard throughout all stages of the claim
    • Real time payment is possible - but not always preferred by insurers
    • SOA can help solve some pain points from consolidation
  • Payers should consider all pricing options when choosing a claims processing system
    • As more healthcare payers use BPO their peers see it as an increasingly attractive option
    • SaaS can provide the balance between BPO and in-house claims processing
  • Healthcare insurers should think twice about standardizing their systems
    • Claims processing can have a powerful impact on an insurers ability to attract and retain customers
    • Consolidation within the industry raises difficult decisions for healthcare insurers
• Competitive Landscape
  • Perot Systems
    • Positioning
  • Oracle
    • Positioning
  • Firstsource
    • Positioning
  • Electronic Data Systems Corporation
    • Positioning
• Go to Market
  • Solutions to ease problems that come from consolidation are crucial
  • Markets outside the US can prove challenging
    • Local knowledge is imperative for vendors wishing to gain traction in new markets
  • Recommendations
    • Vendors should have a deep understanding of healthcare
    • Healthcare insurers need direction to help with dealing with consolidation
    • A one size fits all approach does not work
• APPENDIX
  • Definitions
  • References
  • Methodology
  • Further reading
  • Ask the analyst
  • Datamonitor consulting
  • Disclaimer
  • List of Figures
    • Figure 1: The claims processing lifecycle in healthcare
    • Figure 2: The structure of healthcare in various countries
    • Figure 3: Market for claims processing in US by private and government spend, 2007-2013
    • Figure 4: Market for claims processing in UK by private spend, 2007-2013
    • Figure 5: Market for claims processing in Australia by private and government spend, 2007-2013
    • Figure 6: Market for claims processing in France and Germany by private spend, 2007-2013
    • Figure 7: SWOT Analysis for Perot Systems Corp.
    • Figure 8: SWOT Analysis for Oracle Corporation
    • Figure 9: SWOT Analysis for Firstsource Solutions
    • Figure 10: SWOT Analysis for EDS
    • Figure 11: Claims processing Market Size, USA, UK, France, Germany, Australia and Canada (2007-2013)

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