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

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)