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

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 pandemic initiated a financial downturn for healthcare providers, who were already grappling with administrative inefficiencies, as elective surgeries were halted, and foot traffic decreased. Although patient volumes are gradually returning to pre-pandemic levels, the unprecedented talent shortage exacerbated by the pandemic is posing severe challenges for healthcare providers. As a result, healthcare providers are reconsidering their Revenue Cycle Management (RCM) strategy to future-proof their operations against unexpected disruptions. As part of this strategic overhaul, healthcare providers are becoming more open to outsourcing and even offshoring certain operations to third-party providers. The objective is to alleviate cost pressures and ensure the continuity and consistency of operations. Healthcare providers are also seeking to transform their revenue cycle function by adopting technology to reduce their reliance on talent and streamline operations. Recognizing this opportunity, multiple RCM start-ups with a focus on transforming RCM functions have emerged over the past decade. These start-ups are constantly innovating to provide agile, scalable, and easily integrable out-of-the-box solutions that deliver deep insights and prescriptive suggestions. In this report, we assess start-ups that offer dedicated services, software, and solutions mainly focused on the RCM market, and evaluate their core capabilities and market impact. Scope Industry: healthcare Geography: global Contents In this report, we: Explore the drivers leading to outsourcing in the RCM market Discuss upcoming themes in the RCM industry Provide an outlook on technology enablers in the RCM market Introduce a framework to evaluate high-potential start-ups in the RCM market Highlight the trailblazers in RCM, including their assessment, leaderboard, and profiles Membership (s) Healthcare Payer and Provider Business Process Healthcare Payer and Provider Information Technology Sourcing and Vendor Management

Claims processing is becoming ever more complex for payers given issues such as the need to transform healthcare plans’ business models to accommodate new markets and new lines of business; and increasing inflow of members; and, increasing regulatory mandates. Payment integrity is a potential help – in can reduce rising healthcare waste and fraud to ensure that the medical claims are paid correctly and free of wasteful and abusive practices. Payers’ traditional pay and chase approach has resulted in provider abrasion and has limited the recovery of over-/incorrectly paid claims. Payment integrity product vendors provide solutions that analyze a claim in both the pre- and post-submission phases, using advanced analytics and data mining tools and solutions. They use patterns identified across billions of lines of claims to predict errors, helping payers make required corrections before processing claims. In this report, we analyze 11 payment integrity solutions vendors’ capabilities and map them on the Everest Group PEAK Matrix™, a composite index of distinct metrics related to a vendor’s vision & capability and market impact. This report offers: Market trends for payment integrity and the associated solutions market Information on the payment integrity solutions vendor landscape An assessment of the vendors on several vision & capability- and market impact-related dimensions Vendors covered:Burgess, Change Healthcare, ClarisHealth, Cotiviti, EXL, FICO, FraudLens, HMS, IBM (Truven), LexisNexis, and Optum Scope of this report: Industry: Healthcare payers Services: Payment integrity solutions Geography: US Content: This report has four key sections, each containing insights into the payment integrity solutions landscape: Summary of key messages Payment integrity solutions – market overview PEAK Matrix for payment integrity solutions, which maps vendors on the Everest Group PEAK Matrix and analyzes individual vendor capabilities along the following dimensions: Vision and capability Vision and strategy Technology capability Services capability Innovation and investments Engagement and commercial model Market impact Market adoption Portfolio mix Value delivered Profiles of payment integrity solution vendors: Vendor vision and strategy related to payment integrity solutions General overview of the vendor’s payment integrity solutions business – scale, overall focus, scope, and extent of adoption across enterprise lines of business, processes, and buyer sizes Overview of the vendor’s payment integrity solutions Assessment of the vendor’s payment integrity domain investments and innovative initiatives, and partnerships/alliances Memebership(s) Healthcare IT Services (ITS)