As the global healthcare industry continues to expand, and healthcare accessibility increases, demand for medical insurance also increases. Healthcare providers are facing challenges in maintaining optimal quality of service. Number of medical claims is increasing with increasing incidence of diseases and hospitalizations. Processing claims is an additional and non-core function of healthcare providers. In-house processing of claims by healthcare providers involves a risk of delayed payment, accounting errors, and customer dissatisfaction. Moreover, healthcare providers need to be updated with changes in regulations and new services and products being launched in the market for in-house processing of claims, which adds to time and cost. Outsourcing of medical claims reduces error and improves claims turnover, thereby reducing risks and overall cost to the organization.
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According to the American Medical Association (AMA), 20% error rate among health insurers represents an intolerable level of inefficiency that causes a loss of around US$ 17 billion each year. This depicts a strong need for adequate and technically advanced claim processing services and software to reduce the economic burden.
Moreover, with the advent of healthcare IT, most claims are now electronically made i.e. electronic data interchange. The onset of online medical claim process reduces paperwork of healthcare providers and also assists in rendering adequate fees for the services. Usually the medical claims are processed by medical claims examiners or medical claims adjusters. In case of large number of claims though, medical directors review the claim and validate its authenticity. The medical claims processing services market can be analyzed for:
- Claim indexing
- Claim investigation
- Claim adjudication
- Claim repricing
- Claim settlement
- Litigation management and
- Information management services
Most of these services are either directly rendered by the service provider or can be outsourced to third-party organizations for code assignment and claim processing. Most billing services charge a percentage of the collected claim amount. The concept of EMR/EHR has also streamlined claim processing, as patient records are electronically transmitted to the billing service providers, which eliminates the process of recording and sending paper-based records.
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Better market scenario in developed economies compared to emerging economies
According to Swiss Re, the global insurance penetration rate was a mere 6.2% in 2014. India had the lowest insurance penetration rate at just 3.9% in the same year which decreased to 3.2% in 2015. The U.S., Japan, U.K., Australia, Italy, and France are some of the leading countries in the global medical claims processing services market, owing to higher insurance penetration rate, higher number of claims, and growing demand from healthcare providers. Furthermore, favorable healthcare policy and government initiatives such as the Affordable Care Act have also boosted demand for medical claim processing services in the U.S. Europe is quickly emerging as another important medical claims processing services market. However, introduction of Solvency II in Europe may have an adverse impact on the insurance operators in Europe.
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Although the medical claims processing services market in Asia Pacific and Rest of the World are still at a very nascent stage, high population base and increasing awareness for insurance in the middle income group is expected to boost demand for medical claim processing services in the near future.
Medical claims processing services market competitive landscape
Geographical expansion of global players is leading to increasing competition. Key players are adopting new operating models to achieve maximum efficiency rate. Claims processing companies are at the service of insurance providers to reduce the time and efforts of healthcare providers.
Some of the prominent players in the global medical claims processing services market include Aetna Inc., Infinit Healthcare, Invensis Technologies Pvt. Ltd, Humana Inc., UnitedHealth Group, Telegenisys Inc., and Health Care Service Corp.
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