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 In this environment, traditional administrative processes and outdated systems are proving inadequate.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 evolving landscape of Revenue Cycle Management (RCM) highlights how AI, automation, and outsourcing are transforming financial and operational efficiencies for healthcare providers. Despite persistent challenges such as billing complexities and staffing shortages, healthcare leaders are increasingly prioritizing advanced automation, AI-driven decision-making, and cybersecurity to modernize RCM processes. Generative AI is expected to play a vital role in this modernization, with 85% of RCM leaders believing it will enhance efficiency within the next five years. Key applications include real-time eligibility verification, AI-driven chatbots, and automated medical coding, though organizations must address challenges such as data accuracy, compliance risks, and integration with legacy systems. As RCM continues to evolve, technology-enabled outsourcing models are becoming essential for sustainable growth, enabling providers to optimize workflows, reduce costs, and enhance patient experiences. This report underscores that AI-driven RCM is no longer an option but a necessity for healthcare providers seeking financial resilience and operational excellence. Additionally, it highlights key considerations for selecting the right RCM partner and outlines how third-party providers can enhance RCM workflows for greater efficiency and compliance. Scope Industry: healthcare Geography: North America Contents In this report, we explore: Key RCM challenges healthcare providers face Investment priorities for 2025 through 2030 Current adoption of advanced analytics and intelligent automation, along with priority use cases The emergence of generative AI in RCM, healthcare providers’ readiness, key use cases under consideration, and mitigation strategies for associated risks and barriers An outsourcing strategy for healthcare providers to transition to a technology-powered outsourcing model Membership(s) Healthcare Payer and Provider Business Process Sourcing and Vendor Management

In recent years, technology enterprise adoption and digitalization have significantly reshaped Revenue Cycle Management (RCM), transforming how healthcare providers optimize financial performance and patient engagement. To enhance provider reimbursements, streamline claims processing, and accelerate value-based care initiatives, healthcare providers have made digital adoption their RCM strategies’ foundation. To meet growing enterprise demands, RCM platform providers are expanding their capabilities through investments in AI/gen AI-driven automation, strategic partnerships, and acquisitions to drive efficiency and financial sustainability. In this report, we evaluate 22 RCM platform providers mapped on the Everest Group PEAK Matrix® framework. The report analyzes the RCM platform market size, growth trends, and key capabilities, offering insights into market success metrics. It offers enterprises the information they need to make informed sourcing decisions in the evolving RCM landscape. Scope Industry: healthcare Product: revenue cycle management Geography: US Contents In this report, we: Assess healthcare RCM platforms market trends Examine each platform provider’s capability and market success-related dimensions Analyze platform providers’ key strengths and limitations Membership(s) Healthcare Payer and Provider Information Technology Revenue Cycle Management Sourcing and Vendor Management

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 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

The healthcare industry is transforming rapidly, driven by rising costs, stricter regulations, and a growing emphasis on member experience. This pressure highlights the need for healthcare payers to improve efficiency and effectiveness, especially in light of recent cybersecurity incidents such as the one involving Change Healthcare. Robust information security protocols are essential in this complex environment, where innovative solutions can streamline operations, ensure scalability, and deliver cost-effective care. Amid these challenges, Business Process as a Service (BPaaS) has emerged as a transformative force in healthcare. BPaaS offers a new approach to managing administrative and clinical tasks, leveraging platform-based solutions, deep healthcare expertise, and cutting-edge technology to empower healthcare payers. By embracing BPaaS, organizations can streamline processes, achieve greater scalability, and pursue operational excellence. In this report, we explore the role of BPaaS solutions within the healthcare payer landscape. It provides a comprehensive analysis of the challenges that healthcare enterprises face and demonstrates how BPaaS can effectively address them. The report offers insights into various BPaaS solutions, including their core elements and the outcomes they deliver. Additionally, it examines successful use cases of specialized BPaaS solutions designed to address specific pain points. Furthermore, the report highlights the increasing adoption and potential of BPaaS-led transformation in payviders. Lastly, it provides guidance on evaluating and selecting BPaaS solution providers to navigate the evolving healthcare landscape effectively. Scope Industry: healthcare Geography: global Contents In this report, we examine: The challenges in the enterprise market and how BPaaS can help solve these issues Broad-based BPaaS solutions, including their key elements and the operational efficiency benefits they offer Specialized BPaaS solutions, highlighting successful use cases and targeted approaches to address specific pain points The unique intersection of BPaaS in payviders, including Provider Sponsored Health Plans (PSHPs) BPaaS’ role in navigating the ever-evolving terrain of the healthcare landscape Membership(s) Healthcare Payer and Provider Business Process Outsourcing Excellence

Healthcare payers have long prioritized member experience, investing significantly to improve customer satisfaction. However, their approach has often been incremental, rather than transformative, leading to a notable gap between customer expectations and the actual experience provided. Intensifying competition, regulatory pressures, and evolving consumer standards from industries such as retail and entertainment have heightened the urgency for payers to address this challenge promptly. To bridge this gap, health plans are recognizing the need for embracing technologies such as analytics, automation, cloud, and AI. The emergence of generative AI presents an exciting opportunity to revolutionize member interactions, enabling health plans to make better decisions and deliver personalized healthcare solutions. In this viewpoint, we examine the fundamental challenges impacting member experience within health plans, highlighting the importance of transformative strategies to address these issues. The report also explores the essential digital capabilities required for future member engagement, emphasizing the vital role of technology in meeting the evolving needs of healthcare consumers. Additionally, it examines the role of third-party providers in reshaping member experience and fostering a more connected, customized, and continuous member experience. Enterprises and providers across the healthcare industry can leverage this report to enhance their capabilities and thrive in a digitally enabled future, centered around the needs of members. Scope Industry: healthcare Geography: global Contents In this report, we examine: Foundational customer experience issues in healthcare payer member experiences The defining pillars of next-generation member engagement strategy, employing the 3C approach Key digital capabilities vital for future-proofing member engagement Generative AI’s role in reshaping member experience Third-party providers’ potential contribution in facilitating member journey transformation Membership(s) Healthcare Payer and Provider Business Process Outsourcing Excellence

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