On an average, a payer spends 85-90% of its revenue on claims payments, and, hence, an efficient claims management process is vital for cost optimization. However, current workflows are characterized by a heavy dependence on manual processes and siloed operations, resulting in pricing and billing errors, incorrect claims denials, and high claims processing times.

In this Everest Group research, we showcase the current state of payers’ claims management processes and the associated inefficiencies. To overcome these efficiencies, payers need to adopt a digitalization approach that allows them to build a digital layer over their existing claims management systems, rather than embracing a rip-and-replace approach, which is marred by limitations such as high costs, downtime, and data loss. Such a digital claims management model, characterized by Artificial Intelligence (AI) / Machine Learning (ML) tools and strong IT and business collaboration, will enable payers to accelerate the claims settlement cycle, improve accuracy, and drive cost savings.

Scope

Industry: Healthcare payer

Geography: US

Contents

In this viewpoint, we study:

• Inefficiencies in the existing claims management workflow
• Scaled digital adoption in the claims management workflow
• Enablement of business and IT collaboration
• The business case for change

Membership (s)

Healthcare Payer and Provider Information Technology

Sourcing and Vendor Management