Introduction

The healthcare payer market is undergoing a rapid transformation. With ObamaCare taking effect and boosting enrollments, several new payers find themselves overwhelmed while handling an unprecedented surge in the volumes. Also, as a result of the Affordable Care Act and the increase in the size of the aging population, a greater number of high-risk individuals are now able to enroll for health plans than ever before. This naturally leads to more claims, in terms of both number and value.

In such a scenario, BPO has a much more relevant role to play in the industry. Service providers can help payers streamline their claims operations and reduce operational costs. They can provide services that help buyers bring out new plans in the market more frequently with minimal overheads. Providers can also help run data analytics that can impact the bottomline by targeting low-risk individuals as well as reducing cases of fraud, waste, and abuse.

In this study we analyze the healthcare payer BPO market. We focus on:

• Market overview and buyer adoption trends
• Positioning of 15 service providers on the Everest Group PEAK Matrix for healthcare payer BPO
• Key insights on the PEAK Matrix dimensions
• Healthcare payer BPO solution characteristics

Scope of analysis

• Third-party healthcare payer BPO contracts; it does not include shared services or Global In-House centers (GICs)
• Over 180 active healthcare payer BPO contracts signed as of December 2013
• Coverage across 15 healthcare payer BPO service providers: Accenture, Cognizant, Dell, EXL, Firstsource, Genpact, HCL, Hexaware, HGS, HP, IGATE, Infosys, Sutherland Global Services, Wipro, and Xerox

This report focuses on service providers’ positions on the Everest Group PEAK MatrixTM, assessment of their delivery capabilities, and estimation of their market success. The report incorporates market overview and service provider landscape. The report also includes comments on the delivery capability of each of the service providers considered for the study.

Following are some excerpts from the report:

• Market overview and service provider landscape
• Healthcare payer BPO market is growing at a rapid pace driven by ObamaCare and other regulatory/market changes
• New buyer segments are emerging in this market and driving a large part of the growth
• Factors, such as rise of health insurance exchange, increased regulatory governance, control of fraud, waste, and abuse, and convergence of payers and providers, are likely to impact the future of the BPO industry
• Healthcare payer BPO solution characteristics have been analyzed along the following dimensions:
• Process scope – while claims management continues to drive bulk of BPO adoption, other processes are growing at a much faster pace
• Global sourcing – FTEs are spread across both onshore and offshore locations with three regions (India, Philippines, and North America) accounting for the bulk of the delivery
• Technology solutions – Adoption of platform-based technology is on the rise
• Pricing models – Buyers exhibit maturity by adopting more complex pricing mechanisms
• Healthcare payer BPO PEAK Matrix for 2014

Everest Group classifies 15 healthcare payer BPO service providers on the Everest Group’s proprietary PEAK Matrix framework into:

• Leaders – Accenture, Cognizant, Dell, and Xerox
• Major Contenders – EXL, Firstsource, Genpact, HGS, HP, IGATE, Sutherland Global Services, and Wipro
• Emerging Players – HCL, Hexaware, and Infosys
• Service provider profiles compendium
• The report profiles 15 service providers with robust healthcare payer BPO capabilities
• The profiles provide an overview of the service provider capabilities in delivering healthcare payer BPO solutions

Everest Group has a complimentary four-page PEAK Matrix preview document for this service provider landscape report.