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Medical claims processing services refer to the administrative, operational, and technical services provided by companies to healthcare payers and providers for managing all aspects of medical claims processing and payment. This includes review of medical documentation, verification of membership, application of business rules, and payment determination. Medical claims processing services help providers reduce costs by outsourcing administrative functions and focus on patient care activities. They offer providers access to advanced technologies, skilled resources, and streamlined workflows for efficient processing of millions of claims annually. Common services include claims adjudication, payment processing, eligibility verification, subrogation services, audit and investigation services.
The global medical claims processing services market is estimated to be valued at US$ 28.2 billion in 2023 and is expected to exhibit a CAGR of 4.4% over the forecast period 2023 to 2030, as highlighted in a new report published by Coherent Market Insights.
Rising healthcare costs have prompted payers and providers to focus on optimizing revenue cycles through claims outsourcing partnerships. Further, regulatory compliance requirements and evolving billing standards increase the operational complexity for in-house processing. This has been a major driver for the growing demand for medical claims processing outsourcing across the globe.
Market Dynamics:
Growing demand for outsourcing claims has been a key driver for the medical claims processing services market. Outsourcing non-core claims functions helps providers focus on patient care activities while paying companies take responsibility of administrative workload, skilled workforce and infrastructure. This has helped reduce costs for providers substantially. Another major driver has been increasing healthcare costs which have prompted payers and providers to optimize revenue cycles through claims processing outsourcing partnerships and achieve cost efficiencies. This has propelled the growth of medical claims processing services market globally.
Segment Analysis
Medical claims processing services market is segmented into-
Private Medical Insurance- This is the dominating sub-segment as majority of the people in developed countries opt for private medical insurance over government schemes. These private insurers outsource their claims processing activities to third party providers to reduce costs and focus on core insurance business.
Government Medical Insurance- Claims processing under government run medical insurance schemes is a growing segment driven by expansion of schemes like Medicaid in US and universal healthcare schemes in Europe. However private insurance processing remains the largest segment currently.
PPO (Preferred Provider Organization)- As more employers switch to PPO plans from traditional health insurance, the medical claims processing under these plans is witnessing higher growth compared to other segments.
PEST Analysis
Political- Expansion of universal healthcare in major countries will boost demand for external claims processing from government bodies. Regulations around data privacy and security are increasing compliance requirements.
Economic- Rising healthcare costs are encouraging more people to opt for insurance which is driving volumes. Recession can impact discretionary insurance take-up affecting this market.
Social- Aging population is a major driver as elderly need more medical treatments. Growing lifestyle diseases also influence demand. Digital adoption is increasing processing volumes.
Technological- Automation, artificial intelligence, blockchain are being leveraged to make claims processing more efficient, traceable and faster. Online portals are replacing paper-based processing.
Key Takeaways
The global medical claims processing services market is expected to witness high growth over the forecast period led by expansion of healthcare coverage worldwide. The global medical claims processing services market is estimated to be valued at US$ 28.2 billion in 2023 and is expected to exhibit a CAGR of 4.4% over the forecast period 2023 to 2030.
The North America region currently dominates due to presence of large private insurers and government-run programmes. Major players in are focusing on offerings in niche areas like dental, vision and coding audits as well and leveraging latest technologies to gain efficiencies. Mandatory medical insurance under Affordable Care Act boosted external processing. Europe follows due to universal healthcare schemes while Asia Pacific is fastest growing with China and India leading volumes due to population size and expanding insurance penetration.
Key players
Key players operating in the medical claims processing services market are Optum, Inc., Athenahealth, Inc., Invensis Technologies Pvt Ltd, Aetna Inc., Infosys Limited, Cognizant Technology Solutions, and Accenture plc. Optum leads with over 30% market share owning both core MEDICAL CLAIMS PROCESSING SERVICES provider Optum360 and payer OptumHealth. Athenahealth is pure play provider.
*Note:
- Source: Coherent Market Insights, Public sources, Desk research
2. We have leveraged AI tools to mine information and compile it
Ravina Pandya, Content Writer, has a strong foothold in the market research industry. She specializes in writing well-researched articles from different industries, including food and beverages, information and technology, healthcare, chemical and materials, etc. With an MBA in E-commerce, she has an expertise in SEO-optimized content that resonates with industry professionals.
