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.

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

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

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

Life sciences enterprises are recognizing the strategic importance of selecting the right service providers to enhance their competitive edge in an ever-evolving market. To achieve differentiation, enterprises are seeking partnerships that deliver tangible benefits, such as higher RoI, resilience amid challenging times, robust capabilities, and a distinct market positioning. Notably, enterprises have become more discerning in their partnerships and are seeking providers with a deep commitment to their successes and the credentials and capabilities to back their promises. This report examines the life sciences industry’s sourcing landscape and provides insights for service providers striving to align their offerings with the buyers’ needs and expectations in a dynamic market and amid tight regulatory pressures. Scope Industry: life sciences Geography: global Contents In this report, we examine: Life sciences enterprises’ provider selection criteria Life sciences enterprises’ investment priorities Key outsourcing drivers and challenges Life sciences enterprises’ extent of satisfaction with providers across dimensions Membership(s) Life Sciences Information Technology Life Sciences Business Process Sourcing and Vendor Management

The payment integrity market is dynamically transforming, continuously adapting and enhancing fundamental capabilities within the healthcare industry. The growing emphasis on ensuring accurate and efficient payment processes is creating various opportunities. Key trends gaining prominence include advances in fraud detection and prevention technologies, using sophisticated data analytics for claims validation, integrating AI to identify irregularities, and implementing predictive modeling to forecast potential risks. The industry is experiencing a surge in collaborations and partnerships among payment integrity solution providers, healthcare organizations, and regulatory bodies to create robust ecosystems that foster innovation. Additionally, there is a notable shift toward leveraging next-generation technologies, such as generative AI, to enhance payment accuracy. This evolution underscores the industry’s commitment to refining payment integrity practices through technology innovation and strategic collaborations. In this report, we analyze 18 payment integrity solutions providers featured on the Payment Integrity Solutions PEAK Matrix®. The report positions providers’ market shares 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: global The assessment is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading payment integrity solutions providers, client references, and Everest Group’s ongoing analysis of the payment integrity solutions market Contents This report analyzes 18 payment integrity solutions providers and includes: Providers’ relative positioning on Everest Group’s PEAK Matrix® for Payment Integrity Solutions Providers’ capabilities and market shares Key strengths and limitations Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

The healthcare industry faces challenges such as a shortage of clinical talent, a growing elderly population, and disparities in care access. Chronic diseases are on the rise, influenced by lifestyle choices and air quality. According to the CDC, chronic diseases chronic diseases contribute significantly to increased healthcare spending and mortality. To bridge this gap, healthcare organizations must deliver cost-effective care, expand infrastructure, and address Social Determinants of Health (SDoH) to improve access. Proactively identifying high-risk patients is essential for efficient resource allocation and cost reduction. Innovations in care delivery, targeted interventions, and investments are required to enhance care quality and outcomes. In this viewpoint, we discuss the trends driving care management policies’ adoption, outsourcing opportunities, and the evolution of care delivery. It also highlights challenges in delivering quality care and suggests ways for providers to support enterprises in overcoming these obstacles, with the ultimate goal of achieving superior patient care outcomes. Scope Industry: healthcare Geography: North America Contents In this report, we examine: Key market trends driving the increased outsourcing of care management operations A look into the past, present, and future dynamics of healthcare models Key challenges that enterprises face in handling care management operations and the solutions providers offer to support them Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

Healthcare Payer Operations Provider Compendium provides accurate, comprehensive, and fact-based snapshots of 29 service providers, including their scale of operations, company overview, recent developments, key delivery locations, major clients, technological solutions, and Everest Group’s PEAK Matrix® service provider assessment. The compendium also sheds light on the global healthcare payer operations service provider landscape. The study will enable current and potential buyers of payer operations to assess the providers on their areas of strength and limitations, based on desired capabilities. Scope: Industry: healthcare BPS Geography: global This report is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading healthcare payer operations service providers, client reference checks, and an ongoing analysis of the healthcare payer operations market Contents: Each service provider profile captures the following healthcare payer operations related details: Scale of operations: overview of revenue, client, and FTE base, revenue split by buyer size and geography, as well as FTE split by delivery location and subprocesses Key leaders, suite of services, recent developments, and list of major clients Technology solutions Everest Group's assessment: service provider’s position on the Everest Group PEAK Matrix® and overall evaluation of service provider capabilities with key strengths and limitations Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

Healthcare Data and Analytics (D&A) Services Provider Compendium provides accurate, comprehensive, and fact-based snapshots of 35 providers, including their scale of revenue, overview of client base, company overview, revenue split by geography, segment, value chain, and buyer size, along with Everest Group’s PEAK Matrix® service provider assessment. The compendium also examines the global healthcare D&A service provider landscape. The report will enable current and potential buyers of payer operations to assess the providers on their strengths and limitations, based on their desired capabilities. Scope Industry: healthcare Geography: global This report is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading healthcare D&A services providers, client reference checks, and an ongoing analysis of the healthcare D&A services market Contents Each provider profile captures the following details: Scale of operations: client base overview, revenue, revenue split by segment, value chain, buyer size, and geography Major case studies and consultative frameworks Proprietary solutions and key events Everest Group assessment: providers’ position on Everest Group’s PEAK Matrix® and overall evaluation of provider capabilities with key strengths and limitations Membership (s) Healthcare Payer and Provider Information Technology Healthcare Payer and Provider Business Process Data & Analytics Sourcing and Vendor Management

The healthcare industry constantly evolves, requiring organizations to continuously adapt and enhance their capabilities to stay competitive. The shift toward value-based care has presented various opportunities such as telehealth, population data analytics, remote patient monitoring, commercial models based on risk assessment, increased investment in care management, and a greater emphasis on digital initiatives, particularly automation and analytics. To achieve these objectives, healthcare providers are forging robust partnerships within ecosystems, collaborating with top third-party providers, developing innovative technological solutions, and implementing novel approaches such as Business-Process-as-a-Service (BPaaS) and provider solutions for service delivery. In this report, we analyze 29 healthcare payer operations providers featured on the Healthcare Payer Operations PEAK Matrix® . The report positions the providers’ market shares 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: global The assessment is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading healthcare payer operations providers, client reference checks, and an ongoing analysis of the healthcare payer operations market Contents This report analyzes 29 healthcare payer operations providers and includes: Assessment of the providers’ relative positioning on Everest Group’s PEAK Matrix®  for Healthcare Payer Operations Comparison of the providers’ capabilities and market shares Providers’ key strengths and limitations Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management