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  • June 30, 2025
    The payment integrity market is shifting from post-payment recovery to a proactive focus on pre-payment accuracy, aiming to reduce costs and improve efficiencies. AI is enhancing fraud detection, real-time claims validation, and predictive risk modeling. Simultaneously, blockchain is helping boost transparency, while cloud adoption supports automation and operational agility. Collaboration among payers, providers, and regulators is also strengthening, helping develop more integrated and effective ecosystems. This report assesses 24 payment integrity providers, analyzing key aspects such as revenue scales, client bases, delivery models, value chain coverages, service segmentations, plan sizes and types, notable clients, and proprietary tools. It is designed to help healthcare payers identify the right partners to support operational transformation and gain a competitive edge in a rapidly evolving payment integrity environment.
  • May 27, 2025
    Inclusive and sustainable sourcing is quickly becoming a business must-have – especially in global markets like the UK, EU, and Asia-Pacific, where enterprises face growing pressure to show progress on ESG goals. Organizations are also seeking scalable ways to drive social impact that aligns with their values, sourcing strategies, and digital transformation goals. Watch Everest Group’s experts as they spotlight the firm’s Clinton Global Initiative (CGI) pledge to impact 1 million lives through impact sourcing by 2030, creating economic opportunities by providing skills and jobs to underserved communities globally. We explored how Everest Group is helping accelerate this movement by partnering with enterprises, service providers, and ecosystem enablers to embed inclusive and sustainable sourcing into business strategies. Attendees learned actionable tactics to balance business needs with social responsibility. What questions did the webinar answer for the participants? How will impact sourcing evolve over the next 3 years – especially as AI transforms workforce needs? What role does the Clinton Global Initiative (CGI) ecosystem play in enabling enterprises to create inclusive, skilled talent pipelines? How can companies align impact sourcing with their ESG, talent, and digital transformation goals – while driving measurable business outcomes?
  • April 03, 2025
    The payment integrity market is strategically shifting from post-payment recovery to proactive pre-payment accuracy, thereby reducing costs and enhancing efficiency. AI-driven tools are advancing fraud detection, real-time claims validation, and predictive risk modeling, while next-generation technologies, such as blockchain, are being explored for transparency. The industry is also seeing stronger collaborations among solution providers, healthcare organizations, and regulators to build integrated ecosystems. Additionally, cloud-based platforms are gaining traction and reinforcing the drive toward automation, efficiency, and improved payment accuracy in an evolving healthcare landscape. Scope Industry: healthcare Geography: global Contents This report analyzes 24 payment integrity solutions providers and includes their: Relative positioning on Everest Group’s PEAK Matrix® for payment integrity solutions Capabilities and market shares Key strengths and limitations
  • March 06, 2025
    The Utilization Management (UM) healthcare market faces challenges such as administrative burdens in prior authorization and inconsistent clinical criteria, causing delays and inefficiencies. To overcome these issues, payers are partnering with specialized UM service providers, integrating generative AI, automation, and clinical expertise to streamline workflows and enhance decision-making. Payers are increasingly adopting outcome-based pricing models, linking payments to patient health outcomes rather than service volume. These collaborations improve operational efficiency, accelerate care delivery, reduce costs, and ensure high-quality, evidence-based patient care, ultimately boosting provider alignment and patient satisfaction. In this report, we analyze 18 providers featured on the Utilization Management Operations PEAK Matrix®. The report positions providers relative to each other and evaluates their strengths and limitations. The study will enable healthcare payers to identify suitable providers to transform their business processes and differentiate themselves from competitors. Scope Industry: healthcare Geography: US This assessment is based on Everest Group’s annual RFI process for the calendar year 2024, interactions with leading UM operations providers, client reference checks, and an ongoing analysis of the UM operations market Contents In this report, we examine: The Utilization Management Operations PEAK Matrix® Assessment 2025 The UM operations provider landscape Providers’ key strengths and limitations Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management
  • Feb. 12, 2025
    The healthcare payer market is poised for significant shifts in 2025, driven by growing Medicare Advantage enrollments, rising medical loss ratios, and evolving regulatory frameworks. Payers are facing increasing financial and operational pressures, requiring a strategic focus on cost efficiency, value-based care, and technology adoption. As healthcare expenditures rise and enrollment dynamics shift, service providers have a vital role in supporting payers with technology-enabled solutions. This report analyzes key market trends, buyer priorities, and outsourcing opportunities in 2025. It examines the evolving payer landscape, key digital solutions, and capabilities expected to be in demand across payer functions, including claims management, care management, risk adjustment, and payment integrity. By offering strategic insights and actionable recommendations, this report equips service providers with the recommendations needed to help payers navigate the complex healthcare ecosystem and capitalize on emerging growth opportunities. Scope Industry: healthcare Geography: US Services: payer Contents In this report, we focus on: Key trends shaping the healthcare payer market in 2025 Key buyer priorities from Everest Group interactions and surveys in the healthcare payer market The market’s future outlook Memberships Healthcare Payer and Provider Business Process Sourcing and Vendor Management
  • Dec. 16, 2024
    The healthcare payer outsourcing market is rapidly evolving as payers strive to enhance efficiency, control costs, meet member expectations, and navigate complex regulations. With a growing focus on member-centricity and streamlined core administrative processes, Business Process as a Service (BPaaS) has emerged as a key strategic solution. Payers now demand modular, contextualized, and scalable solutions tailored to specific business lines, such as Medicare or Medicaid. In response, providers are innovating with Line-of-Business (LoB)-specific solutions, robust platform partnerships, and comprehensive consulting capabilities to support payers on their BPaaS transformation journeys. In this report, we provide comprehensive, fact-based snapshots of 14 healthcare payer BPaaS solution providers. The report examines the providers’ revenue scale, client base, deployment models, revenue split by offerings, value chain coverage, plan sizes, plan types, key clients, and proprietary solutions and tools. This research enables healthcare payers to identify suitable providers to transform their business processes and achieve differentiation. Scope Industry: healthcare Geography: US Contents In this report, we examine 14 healthcare payer BPaaS solutions providers based on their: Scale of operations including revenue, client base, deployment model, revenue split by offerings, value chain, plan size, and plan type Key clients and proprietary solutions and tools offered Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management
  • Oct. 08, 2024
    The payment integrity sector is transforming as the healthcare industry seeks to enhance payment process accuracy and efficiency. With rising financial pressures, the demand for effective payment integrity solutions has intensified, prompting stakeholders to explore innovative strategies to manage administrative waste and payment inaccuracies. This viewpoint focuses on a recent significant merger by New Mountain Capital in the payment integrity space that promises to reshape competitive dynamics within the industry. It highlights key enterprise priorities and trends, including the integration of advanced technologies and strategic partnerships aimed at improving operational effectiveness. As stakeholders navigate this changing landscape, insights into the merger's implications will be important for them in understanding how to adapt and optimize their approaches to payment integrity. By examining the evolving market, this viewpoint equips readers with the knowledge to make informed decisions and improve their operations. Scope Industry: healthcare Geography: global Contents In this viewpoint, we explore: A landmark merger in the payment integrity market How the merger addresses key demands in the payment integrity market The merger’s future implications Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management
  • Sep. 26, 2024
    The healthcare payer outsourcing market is rapidly evolving, driven by healthcare payers' need to enhance efficiency, manage costs, meet member expectations, and navigate complex regulations. As the industry shifts toward member-centricity and robust core administrative processes, an integrated platform and operations play, more commonly referred to as Business Process-as-a Service (BPaaS) solutions have emerged as a strong strategic solution to streamline operations. The healthcare payers are demanding modular, contextualized, and scalable solutions that takes care of their specific needs for different business lines such as Medicare or Medicaid. As a result, providers are developing innovative solutions (such as Line-of-Business (LoB) specific or ‘in-a-box’ solutions), robust platform and digital partnerships, and comprehensive consulting capabilities across the value chain to help chart out the BPaaS transformation journey for payers. In this report, we analyze 14 healthcare payer BPaaS solutions providers featured on the Healthcare Payer BPaaS Solutions PEAK Matrix®. The report positions providers relative to each other and evaluates their strengths and limitations. The study will enable healthcare payers to identify suitable providers to transform their business processes and differentiate themselves. Scope Industry: Healthcare Geography: US The assessment is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading healthcare payer BPaaS solutions providers, client references, and Everest Group’s ongoing analysis of the payer BPaaS solutions market Contents The Healthcare Payer BPaaS Solutions PEAK Matrix® Assessment 2024 The payer BPaaS solutions provider landscape Providers’ key strengths, limitations, and capabilities Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management
  • Sep. 17, 2024
    In 2023, US healthcare providers faced formidable challenges. Although patient volumes have started to recover, increased labor expense and talent shortage caused administrative burdens and workflow issues to become more pronounced. Despite slight improvements in hospital margins, denial rates continue to increase, putting pressure on revenue cycle performance and financial stability. Furthermore, being able to access and leverage clean data has become critical given medical coding’s rising complexity and the dynamic regulatory environment. Additionally, the increase in patient responsibility has underscored third-party Revenue Cycle Management (RCM) service providers’ need to provide effective support. As healthcare providers strive to future-proof their revenue cycle operations, the focus remains on enhancing efficiency and mitigating current obstacles. Service providers are responding by scaling their talent pools, enhancing their technology portfolios with automation and analytics, and pursuing mergers and acquisitions to deepen their value chain coverage and remain competitive in the dynamic revenue cycle market. In this report, we assess 29 providers featured on the RCM Operations PEAK Matrix® Assessment 2024. Each profile offers a comprehensive picture of the provider’s service focus through a snapshot of its key strengths and limitations. Scope Industry: healthcare Geography: global Contents In this report, we examine: The RCM Operations PEAK Matrix® Assessment 2024 Key insights into PEAK Matrix® dimensions The RCM business process services provider landscape Providers’ key strengths, limitations, capabilities, and market shares Memberships Healthcare Payer and Provider Business Process Revenue Cycle Management Sourcing and Vendor Management
  • June 11, 2024
    Generative AI might be the first disruptor to spring to mind in 2024, but there are other seismic trends at play that are affecting industries worldwide. Fundamental shifts are developing, brought on by the evolving role of captives, changes in talent management strategies, and new approaches to data exchange/management, which is leading to changes in enterprise operating models. In this webinar hosted by Everest Group experts, Manu Aggarwal, Partner, Ankur Verma, Vice President, and Suman Upardrasta, Vice President, attendees understood how enterprises should think about disruptive changes as they go about their transformation agenda. Our panel discussed effective strategies for thriving in the face of disruption and offered their experienced view on the best path forward. What questions did the webinar answer for the participants? What are the trends impacting enterprises across industries, such as healthcare, life sciences, insurance, and banking and financial services? What are the primary implications for business, technology, and sourcing resulting from these trends? What impact does the adoption of disruptive technologies like generative AI have on the enterprise operating model?What are the common challenges that enterprises are facing as a result? How can the operating models be tweaked or changed to help enterprises move from disruption to transformation?