As the healthcare industry continues to expand globally, healthcare providers are facing challenge in maintaining the highest quality of services. The numbers of claims are increasing with increasing coverage of medical insurance. Processing those claims along with the administrative tasks, patient care, and other daily operations is cumbersome and involves high cost and skilled labor. Processing claims in-house by the healthcare provider has the risk of delayed payment, error in amounting and customer dissatisfaction. Moreover, the healthcare providers need to be updated with the recent changes in regulations and new services and products being introduced in the market for in-house processing of claims. Outsourcing of medical claims ensures minimal error and faster turnover, thereby reducing the risk of delayed payment. According to American Medical Association (AMA), 20% error rate among health insurers represents an intolerable level of inefficiency that causes a loss of about USD 17 billion each year. This clearly depicts a strong need for adequate and technically advanced claim processing services and software to reduce the economic burden.
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Previously the claims were submitted using a paper form but with the advent of healthcare IT most of the claims are now electronically made i.e. electronic data interchange. The onset of online medical claim process not only reduces the paperwork of healthcare provider but also assist in rendering the adequate fees for the services. Usually the medical claims are processed by medical claims examiners or medical claims adjusters. But in case of large number of claims, medical directors review the claim and validate its authenticity.
The medical claim 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 rendered by the service provider directly or can be outsourced to third party organizations for code assignment and claim processing. Outsourcing concept reduces the burden as well as cost for the insurance companies. Most billing services charge a percentage of the collected claim amount. The concept of EMR/EHR has also streamlined the claim processing as patient records are electronically transmitted to the billing service providers which eliminated the process of recording and sending paper based records.
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Demand is high in Developed Economies
Globally, the insurance penetration rate according to Swiss Re was merely 6.2% in 2014, where as in India the rate was just 3.9% in the same year. Moreover, the study by Swiss Re found that the insurance penetration rate fell to 3.2% in 2015 in India. The United States, 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 demand from healthcare providers. Furthermore, favorable healthcare policy and government initiatives such as Affordable Care Act have also boosted the growth and demand for medical claim processing services in the United States. Europe is quickly emerging as another important region in this market. However, introduction of Solvency II in Europe may have an impact on the insurance operators in Europe.
Although Asia Pacific and Rest of the World market are still at a very nascent stage, high population base and increasing awareness for insurance in the middle income group is expected to boost the demand for medical claim processing services in forthcoming years.
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Competitive Landscape
The health insurance industry is becoming more and more competitive with the geographical expansion of global players. New operating models are being followed to achieve maximum efficiency rate. Processing of claims challenges like 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 claim processing 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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