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  • To Be Published : Feb 2024
  • Code : CMI41
  • Formats :
      Excel and PDF
  • Industry : Pharmaceutical

Medical Claims Processing Services

As the global healthcare industry continues to expand, healthcare providers are facing challenges in maintaining optimal quality of services. Number of claims are increasing with increasing coverage of medical insurance. Processing such claims along with the administrative tasks, patient care, and other daily operations is cumbersome and involves high cost and trained personnel. Processing of claims in-house by the healthcare provider has the risk of delayed payment, error in amounting, 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. Outsourcing of medical claims ensures minimal error and faster turnover, thereby reducing risk of delayed payment. 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.

Earlier, claims were submitted using a paper form. However, 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. Outsourcing concept reduces the burden as well as cost for insurance companies. 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.  

Medical Claims Processing Services Industry Outlook is Positive in Developed Economies

According to Swiss Re, the global insurance penetration rate was a mere 6.2% in 2014, with India having insurance penetration rate on the lower side, at just 3.9% in the same year. Moreover, the study found that the insurance penetration rate fell to 3.2% in 2015 in India. 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, increasing number of claims, and growing demand from healthcare providers. Furthermore, favorable healthcare policy and government initiatives such as 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.

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. There are various challenges related to claims processing such as volume of claims, speed of processing, accuracy, regulatory compliance, and administrative costs. Therefore, claims processing companies are at the service of insurance providers to reduce their time and efforts.

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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