This report, co-authored with HfS Research, explores the heavily regulated healthcare payor industry which is in the midst of a continuous flux of its commercial and consumer businesses. Rapid industry developments in the global healthcare industry during the past two years have been a pre-cursor to the advent of new technology and reforms in the industry along with an increase in the amount of outsourcing. There is a dire need to upgrade policies, execution and technology across healthcare systems across the globe. The major healthcare payors currently have a limited experience in labour-arbitrage based outsourcing. The future for the industry requires these payors to increasingly leverage the capabilities of their existing service providers to ensure better quality and win new market share.

Highlights of the report include:

• An increasing demand in global healthcare expenditures as chronic illnesses, lifestyle diseases and an aging population consume more services, products and pharmaceuticals. These costs are putting tremendous pressures on payors to outsource services to streamline their processes and reduce expenses
• The US healthcare industry is highly fragmented and is moving very slowly towards removing inefficiencies in revenue cycle processes
• The healthcare payor BPO marketplace is set to explode as payors require improved technology, greater scalability and lower administrative costs
• Payor differentiation will be determined by network quality and improvements in the health of their members. Payors will require more robust network optimization support models and improved member outreach to compete.
• A breakdown of 25 payor and service provider BPO processes shows opportunity for all stakeholders. The report evaluates major marketing, underwriting, enrollment, billing, claims processing, service, care management, network management, actuarial, human resources, procurement and finance processes for leading outsourcing trends.

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