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Introduction

In challenging market conditions that healthcare payers are faced with this report analyzes the claims processing market for healthcare payers. The report looks at how claims processing can bring an increased return on investment (ROI) to payers and what strategy should be taken in order to achieve successful adoption.

Scope

The evolution of healthcare is creating a challenging environment for healthcare insurers

Consolidation within the industry creates tough technological decisions for insurers

The varied structure of healthcare across the markets creates a challenging environment

Vendors with flexible offerings to healthcare payers will achieve the most success

Highlights

This report looks at the drivers and inhibitors behind claims processing for healthcare payers. It analyzes the strategy healthcare payers need to adopt in order to maximize their success.

Reasons to Purchase

Understanding the challenges facing healthcare payers and how these effect their purchases on claims processing.

View market sizing for US, UK, Germany, France and Australia from 2007-2013

Overview 1
Catalyst 1
Summary 1
Key Messages 2
The evolution of healthcare is creating a challenging environment for healthcare insurers 2
Consolidation within the industry creates tough technological decisions for insurers 2
The varied structure of healthcare across the markets creates a challenging environment 2
Vendors with flexible offerings to healthcare payers will achieve the most success 2
Table of Contents 4
Table of figures 5
Market Opportunity 6
Electronic claims processing is coming to play an increasingly prominent role in healthcare 6
There are multiple drivers pushing healthcare payers to adopt claims processing software 7
The rising cost of healthcare is causing considerable pain points for healthcare payers 7
The increasingly consumerist nature of healthcare is forcing payers to become more competitive 8
The cooling of the global economy will make health insurance more competitive 9
Payers' need to adapt to changing circumstances is driving claims processing adoption 9
Claims processing software enables payers to manage government regulations more easily 9
The continual need to reduce fraud and errors is driving the adoption of claims processing software 10
The culture of healthcare payers is inhibiting the take up of claims processing 10
The fragmented nature of healthcare payers makes claims processing implementations challenging 10
The short term vision of mid-sized healthcare payers is inhibiting progression in claims processing 11
The conservatism of healthcare insurers is limiting their investment in claims processing automation 11
While the US remains the dominant market - other areas offer opportunities for vendors 11
The US is by far the most dominant market for claims processing software 12
While a small market, the UK offers opportunities for vendors to implement claims processing software 13
With its mix of public and private Australia has a need for electronic claims processing 14
Germany and France, while challenging markets, offer opportunities for vendors 15
Customer Impact: Making the right choices 17
The technical advances in claims processing are helping to increase its ROI 17
The automation of claims processing should become standard throughout all stages of the claim 17
Real time payment is possible - but not always preferred by insurers 18
SOA can help solve some pain points from consolidation 18
Payers should consider all pricing options when choosing a claims processing system 18
As more healthcare payers use BPO their peers see it as an increasingly attractive option 19
SaaS can provide the balance between BPO and in-house claims processing 20
Healthcare insurers should think twice about standardizing their systems 20
Claims processing can have a powerful impact on an insurers ability to attract and retain customers 20
Consolidation within the industry raises difficult decisions for healthcare insurers 21
Competitive Landscape 22
Perot Systems 22
Positioning 22
Oracle 23
Positioning 23
Firstsource 24
Positioning 24
Electronic Data Systems Corporation 25
Positioning 25
Go to Market 27
Solutions to ease problems that come from consolidation are crucial 27
Markets outside the US can prove challenging 27
Local knowledge is imperative for vendors wishing to gain traction in new markets 28
Recommendations 28
Vendors should have a deep understanding of healthcare 28
Healthcare insurers need direction to help with dealing with consolidation 28
A one size fits all approach does not work 29
APPENDIX 30
Definitions 30
References 30
Methodology 30
Further reading 30
Ask the analyst 31
Datamonitor consulting 31
Disclaimer 31
List of Figures
Figure 1: The claims processing lifecycle in healthcare 7
Figure 2: The structure of healthcare in various countries 12
Figure 3: Market for claims processing in US by private and government spend, 2007-2013 13
Figure 4: Market for claims processing in UK by private spend, 2007-2013 14
Figure 5: Market for claims processing in Australia by private and government spend, 2007-2013 15
Figure 6: Market for claims processing in France and Germany by private spend, 2007-2013 16
Figure 7: SWOT Analysis for Perot Systems Corp. 23
Figure 8: SWOT Analysis for Oracle Corporation 24
Figure 9: SWOT Analysis for Firstsource Solutions 25
Figure 10: SWOT Analysis for EDS 26
Figure 11: Claims processing Market Size, USA, UK, France, Germany, Australia and Canada (2007-2013) 27