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

Published by: Datamonitor

Published: Mar. 26, 2008 - 32 Pages

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)

Abstract

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