US health insurance carriers face escalating pressures, from soaring costs and workforce shortages to rising member expectations and complex compliance demands. In this environment, traditional administrative processes and outdated systems are proving inadequate. To address these challenges, health plans are embracing next-generation Business-Process-as-a-Service (BPaaS) as a strategic transformation enabler. Unlike earlier models, next-generation BPaaS integrates cloud-based platforms, generative and agentic AI, digital twins, and robust data strategies into unified, scalable service ecosystems. This report explores how next-generation BPaaS helps healthcare payers drive outcomes such as higher auto-adjudication, reduced total cost of ownership, improved regulatory readiness, and enhanced member experiences. It also introduces a 4D transition framework – Discover, Decide, Drive, and Deepen – to guide payers through readiness assessment, provider selection, and continuous optimization. With intelligent platforms, multi-shore delivery, and AI-led decision-making at the core, next-generation BPaaS is enabling health plans to shift from transactional efficiency to strategic transformation.

US healthcare organizations face operational challenges, including rising chronic disease prevalence, workforce shortages, and growing administrative complexity. In this environment, legacy operating models are proving insufficient, prompting healthcare enterprises to reconsider their long-held hesitancy toward clinical outsourcing. As home health expenditures rise and regulatory scrutiny increases, enterprises must reimagine how they deliver efficient, high-quality, and patient-centered care. This Viewpoint explores how strategic clinical outsourcing can address key pressures by enhancing scalability, operational efficiency, and regulatory readiness. By partnering with providers offering skilled clinical talent, digital platforms, and compliance-aligned workflows, enterprises can streamline utilization management, case management, risk adjustment, and quality improvement efforts. The report also emphasizes the importance of aligning automation and AI tools with human expertise to improve outcomes while managing cost and compliance risk. Scope Geography: US Industry: healthcare Service: healthcare business process services Contents In this report, we examine: Key challenges driving the need for clinical outsourcing Functions best suited for outsourcing in clinical operations Strategic benefits of outsourcing: scalability, efficiency, and compliance Key success factors for implementation The evolving role of digital tools and AI in clinical workflows

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

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

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

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

Over the past year, enterprises have faced significant macroeconomic and geopolitical challenges. The potential uncertainties surrounding the implementation of the Inflation Reduction Act (IRA), the escalation in federal interest rates aimed at curbing inflation, and the ongoing conflicts leading to the relocation of clinical trials from regions such as Russia and Ukraine, have prompted enterprises to reassess their strategies. Moreover, the introduction of generative AI technologies, such as ChatGPT, empowers biopharmaceutical and MedTech companies to revamp their offerings and deliver state-of-the-art technology and cost efficiencies. In response to enterprises’ evolving demands, providers are enhancing their capabilities across the life sciences operations value chain. They have directed investments into various avenues, including Decentralized Clinical Trials (DCT), with numerous IT / Business Process Outsourcing (BPO) firms forging partnerships with DCT providers. Furthermore, additional investments encompass analytics-driven tools for precision Healthcare Professional (HCP) profiling and targeting, as well as the adoption of automation tools in areas such as Adverse Events (AE) intake to swiftly adapt to market demands. In this report, we assess 28 life sciences operations service providers featured on the life sciences operations PEAK Matrix®. The study will enable life sciences enterprises to identify suitable providers to transform their business processes and differentiate themselves. Scope Industry: life sciences business process services Geography: global The assessment is based on Everest Group’s annual RFI process for the calendar year 2023, interactions with leading life sciences operations service providers, client reference checks, and an ongoing analysis of the life sciences operations market Contents In this report, we: Examine 28 life sciences operations service providers featured on the life sciences operations PEAK Matrix® Assess providers’ capabilities and market shares Membership(s) Life Sciences Business Process Outsourcing Excellence

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

Over the past one year, enterprises had to overcome a series of macroeconomic and geopolitical challenges. The potential uncertainties with the implementation of the Inflation Regulation Act (IRA), and the rise in federal interest rates to curb inflation, compounded by an ongoing war resulting in shifting of clinical trials from Russia and Ukraine, have forced enterprises to rethink their strategies. Further, the advent of generative AI such as ChatGPT will enable the biopharma and MedTech firms to repackage their offerings and provide cutting-edge technology and cost optimization. To effectively serve the evolving enterprise needs, service providers have invested in increasing the breadth and depth of their functionalities/offerings across the life sciences operations value chain. They have invested in a host of avenues such as Decentralized Clinical Trials (DCT), with many Information Technology / Business Process Outsourcing (IT/BPOs) companies partnering with DCT providers. Further investments include analytics-driven tools for razor-sharp Healthcare Professional (HCP) profiling and targeting, and the use of automation tools in areas such as Adverse Events (AE) intakes to rapidly evolve with the market needs. In this research, we present a detailed assessment of 28 operations service providers featured on the Life Sciences Operations Services PEAK Matrix®. We provide a relative positioning and analysis of the providers’ market shares, along with our evaluation of their strengths and limitations. This report will enable enterprises to identify suitable service providers to manage the evolving needs of their businesses. Scope Industry: life sciences BPS Geography: global The assessment is based on Everest Group’s annual RFI process for calendar year 2023, interactions with leading life sciences operations service providers, client reference checks, and an ongoing analysis of the life sciences operations market. Contents This report provides a detailed analysis of 28 operations service providers and includes: Relative positioning of the providers on Everest Group’s PEAK Matrix® for Life Sciences Operations Services Comparison of the providers’ capabilities and market shares Everest Group’s analysis of the providers’ strengths and limitations Membership(s) Life Sciences Business Process Sourcing and Vendor Management