美国医疗账单管理市场增长机会

美国医疗索赔管理市场预计在 2021 年至 2026 年间以 11% 的复合年增长率增长，到 2026 年将达到 238.1 亿美元。 主要增长驱动因素包括索赔流程的成本和復杂性上升、对基于价值的报销模型的响应、索赔前后流程中欺诈、浪费和滥用 (FWA) 的增加，以及不堪重负的管理和运营。这些包括成本和消费者需求用于数字体验。

本报告考察了美国的医疗索赔管理市场，并对管理软件、服务和技术干预措施进行了定性和定量分析。

内容

战略要务

• 为什么越来越难成长？
• 战略要务 8 (TM)
• 三大战略要务对美国医疗理赔管理行业的影响
• 增长机会推动增长 Pipeline Engine(TM)

增长机会分析

• 分析范围
• 行业之声：影响当今医疗理赔管理的因素
• 付款人和提供商电子管理交易的定义
• 美国的医疗索赔管理：医疗保险和医疗补助服务中心 (CMS) 最近发布的公告
• 美国主要健康保险公司的收入市场份额
• 美国医疗保健支付管理局
• 细分
• 美国医疗索赔管理细分：按技术分类

成长环境

• 理赔管理市场的发展环境
• 付款人和提供商索赔管理工作流程
• 不断发展的关键结算功能的价值主张
• 美国医疗保健付款人功能组件
• 美国医疗保健付款人后台功能组件
• 美国医疗保健付款人索赔处理，主要挑战
• 美国医疗保健付款人面临的主要挑战
• 付款人的多方面智能运营方法
• 推动保险公司打造下一代理赔管理能力的主要趋势
• 趋势 1：健康保险的实时理赔处理
• 趋势 2：新的支付完整性范例
• 趋势 3：付款方与提供商的协作
• 趋势 4：认知数字自动化
• 美国医疗保健理赔管理市场的主要竞争对手
• 增长指数
• 增长动力
• 抑制增长的因素
• 预测假设
• 收入预测
• 按产品分类的收入预测
• 收入预测分析
• 价格趋势和预测分析
• 竞争环境
• 收益分成
• 收益分成分析

增长机会分析：医疗计费和编码领域

• 增长指数
• 收入预测
• 预测分析

增长机会分析：投诉管理和处理部分

• 增长指数
• 收入预测
• 预测分析

增长机会分析：支付集成部分

• 增长指数
• 收入预测
• 预测分析

增长机会分析：BPA 部分

• 增长指数
• 收入预测
• 预测分析

增长机会领域

• 增长机会 1：数字发票功能中的付款人集成
• 增长机会 2：用于智能合约的区块链技术
• 增长机会 3：用于智能付款人自动化的 RPA
• 增长机会 4：预批准 (PA) 自动化和分类中的 AI

下一步

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.

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.

Table of Contents

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™

Growth Opportunity Analysis

• 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

• 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 Opportunity Analysis-Medical Billing & Coding Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Analysis-Claims Administration & Processing Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Analysis-Payment Integrity Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Analysis-BPA Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Universe

• 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)

Next Steps

• Your Next Steps
• Why Frost, Why Now?
• List of Exhibits
• List of Exhibits (continued)
• Legal Disclaimer