美國醫療賬單管理市場增長機會

美國醫療索賠管理市場預計在 2021 年至 2026 年間以 11% 的複合年增長率增長，到 2026 年將達到 238.1 億美元。 主要增長驅動因素包括索賠流程的成本和復雜性上升、對基於價值的報銷模型的響應、索賠前後流程中欺詐、浪費和濫用 (FWA) 的增加，以及不堪重負的管理和運營。這些包括成本和消費者需求用於數字體驗。

本報告考察了美國的醫療索賠管理市場，並對管理軟件、服務和技術干預措施進行了定性和定量分析。

內容

戰略要務

• 為什麼越來越難成長？
• 戰略要務 8 (TM)
• 三大戰略要務對美國醫療理賠管理行業的影響
• 增長機會推動增長 Pipeline Engine(TM)

增長機會分析

• 分析範圍
• 行業之聲：影響當今醫療理賠管理的因素
• 付款人和提供商電子管理交易的定義
• 美國的醫療索賠管理：醫療保險和醫療補助服務中心 (CMS) 最近發布的公告
• 美國主要健康保險公司的收入市場份額
• 美國醫療保健支付管理局
• 細分
• 美國醫療索賠管理細分：按技術分類

成長環境

• 理賠管理市場的發展環境
• 付款人和提供商索賠管理工作流程
• 不斷發展的關鍵結算功能的價值主張
• 美國醫療保健付款人功能組件
• 美國醫療保健付款人後台功能組件
• 美國醫療保健付款人索賠處理，主要挑戰
• 美國醫療保健付款人面臨的主要挑戰
• 付款人的多方面智能運營方法
• 推動保險公司打造下一代理賠管理能力的主要趨勢
• 趨勢 1：健康保險的實時理賠處理
• 趨勢 2：新的支付完整性範例
• 趨勢 3：付款方與提供商的協作
• 趨勢 4：認知數字自動化
• 美國醫療保健理賠管理市場的主要競爭對手
• 增長指數
• 增長動力
• 抑制增長的因素
• 預測假設
• 收入預測
• 按產品分類的收入預測
• 收入預測分析
• 價格趨勢和預測分析
• 競爭環境
• 收益分成
• 收益分成分析

增長機會分析：醫療計費和編碼領域

• 增長指數
• 收入預測
• 預測分析

增長機會分析：投訴管理和處理部分

• 增長指數
• 收入預測
• 預測分析

增長機會分析：支付集成部分

• 增長指數
• 收入預測
• 預測分析

增長機會分析：BPA 部分

• 增長指數
• 收入預測
• 預測分析

增長機會領域

• 增長機會 1：數字發票功能中的付款人集成
• 增長機會 2：用於智能合約的區塊鏈技術
• 增長機會 3：用於智能付款人自動化的 RPA
• 增長機會 4：預批准 (PA) 自動化和分類中的 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