米国の医療費請求管理市場の成長機会

米国の医療費請求管理市場は、2021年～2026年の間にCAGR11％の成長率で増加し、2026年までに238億1,000万米ドルに達すると予測されています。主な成長要因としては、請求プロセスのコスト上昇と複雑化、価値に基づく償還モデルへの対応、請求の事前・事後判断プロセスにおける不正・無駄・乱用（FWA）の増加、圧倒的な管理・運用コスト、デジタル体験に対する消費者の要求などが挙げられます。

当レポートでは、米国における医療費請求管理市場について調査し、管理ソフトウェア、サービス、技術介入に関する定性的および定量的な分析を提供しています。

目次

戦略的必須事項

• 成長がますます困難になっているのはなぜですか？
• The Strategic Imperative 8（TM）
• 米国の医療費請求管理業界に対する上位3つの戦略的必須事項の影響
• 成長機会がGrowth Pipeline Engine（TM）を促進

成長機会分析

• 分析範囲
• 業界からの声：今日の医療費請求管理に影響を与えるもの
• 支払者とプロバイダーの電子管理トランザクションの定義
• 米国の医療費請求管理：Centers for Medicare &Medicaid Services（CMS）による最近の発表
• 米国の主要健康保険会社の市場シェア：収益別
• 米国のヘルスケア保険支払局
• セグメンテーション
• 米国の医療費請求管理セグメンテーション：技術別

成長環境

• 損害管理市場の成長環境
• 支払者とプロバイダーのクレーム管理ワークフロー
• 主要な請求機能の進化する価値提案
• 米国のヘルスケア支払者機能コンポーネント
• 米国のヘルスケア支払者のバックオフィス機能コンポーネント
• 米国のヘルスケア支払者の請求処理、主な課題
• 米国のヘルスケア支払者の主な課題
• 多面的なインテリジェント運用に対する支払者のアプローチ
• 保険会社の次世代請求管理機能を促進する主な動向
• 動向1：健康保険におけるリアルタイム請求処理
• 動向2：新たな決済の完全性パラダイム
• 動向3：支払者とプロバイダーのコラボレーション
• 動向4：コグニティブデジタルオートメーション
• 米国のヘルスケア保険金請求管理市場における主要な競合
• 成長指標
• 成長促進要因
• 成長抑制要因
• 予測の前提条件
• 収益予測
• 収益予測：製品別
• 収益予測分析
• 価格動向と予測分析
• 競合環境
• 収益シェア
• 収益シェア分析

成長機会分析：医療請求およびコーディングセグメント

• 成長指標
• 収益予測
• 予測分析

成長機会分析：クレーム管理・処理セグメント

• 成長指標
• 収益予測
• 予測分析

成長機会分析：支払い統合セグメント

• 成長指標
• 収益予測
• 予測分析

成長機会分析：BPAセグメント

• 成長指標
• 収益予測
• 予測分析

成長機会領域

• 成長機会1：デジタル請求機能における支払者の統合
• 成長機会2：スマートコントラクトのためのブロックチェーン技術
• 成長機会3：インテリジェントな支払人自動化のためのRPA
• 成長機会4：事前承認（PA）自動化とトリアージにおけるAI

次のステップ

Intelligent Tools to Automate Payer and Provider Functions Will Boost Efficiency and Deliver a Digital Customer Experience

The healthcare claims management industry is evolving. Changes include a shifting reimbursement landscape (for virtual care, urgent care, telehealth, and at-home care); a transition to new, value-based care models (e.g., population-based reimbursement and partial and full capitation payment); and disruption from big tech companies, big-box retailers, and big telecom operators entering the primary care and platform play in healthcare domains.

In addition, health consumer empowerment (self-quantified consumers), employer push for greater value in patient care, and regulatory changes are forcing health insurance companies and providers to redesign their claims processes and capabilities by integrating technologies such as robotic process automation (RPA) and artificial intelligence (AI) in claims predictions, prior-authorization, pre/post-adjudication, and payment.

This study offers qualitative and quantitative analysis of select healthcare claims management software, services, and technology interventions for the US market. It also includes in-depth coverage of key vendors' solutions and services across payer and provider back-office operations including claims intake, preparation, pre/post-adjudication, claims adjustment, and payment. These solutions and services cover RPA, AI, clearinghouse, payment integrity, care management, revenue cycle management, and electronic medical record/electronic health record (EMR/EHR) across the provider and payer claims' value chain.

Frost & Sullivan expects the healthcare claims management market to hit $23.81 billion by 2026, increasing at a compound annual growth of 11% (2021 to 2026).

The main growth factors include the rising cost and complexity of claims processes, support for value-based reimbursement models, increasing fraud, waste, and abuse (FWA) in the claims pre- and post-adjudication process, overwhelming administrative and operational costs, and consumer demand for a digital experience.

To keep ahead of their competitors, health insurance incumbents must have a robust process to integrate digital technologies into their core operations to become customer-centric, digitally enabled organizations fit to excel in three foundational areas of claims: customer experience, efficiency, and effectiveness.

Table of Contents

Strategic Imperatives

• Why is it Increasingly Difficult to Grow?
• The Strategic Imperative 8™
• The Impact of the Top 3 Strategic Imperatives on the US Healthcare Claims Management Industry
• Growth Opportunities Fuel the Growth Pipeline Engine™

Growth Opportunity Analysis

• Scope of Analysis
• Voices from the Industry-What Impacts Claims Management Today?
• Voices from the Industry-What Impacts Claims Management Today?(continued)
• Definitions of Payer & Provider Electronic Administrative Transaction
• Definitions of Payer & Provider Electronic Administrative Transaction (continued)
• US Healthcare Claims Management-Recent Announcements by Centers for Medicare & Medicaid Services (CMS)
• Market Share by Revenue of Top US Health Insurance Companies
• US Healthcare Payer Authority
• Segmentation
• Segmentation (continued)
• US Healthcare Claims Management Segmentation by Technology

Growth Environment

• Growth Environment for the Claims Management Market
• Growth Environment for the Claims Management Market (continued)
• Payer and Provider Claims Administrative Workflow
• Evolving Value Propositions of Key Claims Capabilities
• US Healthcare Payer Function Components
• US Healthcare Payer Back-office Function Components
• US Healthcare Payer Claims Processing, Key Challenges
• US Healthcare Payer Top Challenges
• Payers' Approach to Multi-faceted Intelligent Operations
• Key Trends Driving Payers' Next-gen Claims Management Capabilities
• Trend 1-Real-time Claims Processing in Health Insurance
• Trend 2-Emerging Payment Integrity Paradigm
• Trend 3-Payer-Provider Collaboration
• Trend 4-Cognitive Digital Automation
• Key Competitors in the US Healthcare Claims Management Market
• Growth Metrics
• Growth Drivers
• Growth Restraints
• Forecast Assumptions
• Revenue Forecast
• Revenue Forecast by Product
• Revenue Forecast Analysis
• Revenue Forecast Analysis (continued)
• Pricing Trends and Forecast Analysis
• Competitive Environment
• Revenue Share
• Revenue Share Analysis

Growth Opportunity Analysis-Medical Billing & Coding Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Analysis-Claims Administration & Processing Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Analysis-Payment Integrity Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Analysis-BPA Segment

• Growth Metrics
• Revenue Forecast
• Forecast Analysis

Growth Opportunity Universe

• Growth Opportunity 1-Payer Integration of Digital Claims Functions
• Growth Opportunity 1-Payer Integration of Digital Claims Functions (continued)
• Growth Opportunity 2-Blockchain Technology for Smart Contracts
• Growth Opportunity 2-Blockchain Technology for Smart Contracts (continued)
• Growth Opportunity 3-RPA for Intelligent Payer Automation
• Growth Opportunity 3-RPA for Intelligent Payer Automation (continued)
• Growth Opportunity 4-AI in Prior-Authorization (PA) Automation and Triaging
• Growth Opportunity 4-AI in Prior-Authorization (PA) Automation and Triaging (continued)

Next Steps

• Your Next Steps
• Why Frost, Why Now?
• List of Exhibits
• List of Exhibits (continued)
• Legal Disclaimer