The Payment Integrity (PI) market is structurally resetting. Payers are moving from retrospective audits to preventive, pre-payment validation using AI, predictive analytics, and automation to detect anomalies early, improve coding accuracy, and reduce provider abrasion. This prevention-first posture aligns with value-based care and targets lower medical loss ratios, fewer takebacks, and audit-ready defensibility while improving efficiency. Modernizing buyers prioritize outcome-linked pricing, real-time reporting, appeals overturn rates, overpayment and error identification, and domain expertise. They also value flexible deployments, modular platforms, and co-sourced models that augment teams. Transparent payer–provider workflows and data reduce disputes and enable right-first-time payments. This report screens more than 50 PI solution providers, shortlists 18 niche specialists, and profiles 10 high-potential specialists. It features detailed profiles of the 10 high-potential specialists, including company overviews, key executives, core elements, PI offerings, and selected metrics such as year of incorporation, headquarters, and employee count. Everest Group also shares its perspective on each specialist’s business maturity, domain focus, market buzz, technology, leadership, and talent.

The Clinical and Care Management (CCM) operations market is rapidly transforming as payers and providers face mounting pressures from rising care complexity, workforce constraints, and financial risk exposure. Fragmented data systems, coupled with growing regulatory demands, are further amplifying the need for modernized operations that can improve care quality while ensuring compliance and cost efficiency. In this evolving environment, enterprises are increasingly turning to specialized CCM partners that combine deep clinical expertise with next-generation technology. As value-based care adoption accelerates, buyers demand solutions that embed predictive risk modeling, generative AI, and intelligent automation into proven workflows to elevate patient outcomes and optimize clinician productivity. Providers are responding with domain-focused investments, modular platforms, and outcome-linked delivery models that balance efficiency with high-quality care coordination. In this report, Everest Group assesses 20 leading CCM operations providers featured on the Clinical and Care Management (CCM) Operations PEAK Matrix® Assessment 2025. The analysis compares providers against one another and evaluates their strengths, limitations, and differentiating capabilities. This study will enable payers and providers to identify the right partners to modernize CCM operations, drive value-based outcomes, and advance enterprise transformation initiatives.

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 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

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 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