Stratistics MRC에 따르면 세계의 헬스케어 청구 관리 솔루션 시장은 2025년에 162억 8,000만 달러를 차지하고 예측 기간 중 CAGR은 6.7%를 나타내 2032년에는 239억 4,000만 달러에 달할 것으로 예측되고 있습니다.
헬스케어 청구 관리 솔루션은 헬스케어 청구의 처리를 간소화하고 자동화하기 위해 설계된 시스템과 프로세스를 의미합니다.
2021년 Flexera의 조사에 따르면 조직의 93%가 클라우드 기술을 사용했으며 73%가 비용 절감을 위해 클라우드 사용을 최적화했습니다.
의료보험 보급률 증가
건강 보험의 보급률이 높아지면 의료 제공업체와 보험자가 효율적으로 처리해야 하는 청구의 양이 늘어납니다. 헬스케어 조직은 정확한 청구, 적시 환불 및 규제 준수를 보장하기 위해 견고한 시스템을 필요로 합니다.
데이터 프라이버시에 대한 우려
헬스케어 청구 관리 솔루션의 데이터 프라이버시에 대한 우려는 환자의 건강 정보의 기밀성과 HIPAA 및 GDPR(EU 개인정보보호규정)과 같은 데이터 보호 규정에 대한 엄격한 규정 준수의 필요성으로 인해 발생합니다. 이러한 프라이버시에 대한 우려는 사이버 보안 및 규정 준수 프로토콜에 많은 투자를 필요로 하는 경우가 많으며, 헬스케어 조직의 비용을 증가시키고 청구 관리 솔루션의 보급을 방해하기 때문에 시장 성장을 방해하고 있습니다.
클라우드 헬스케어 솔루션에 대한 수요 증가
클라우드 솔루션을 통해 의료 조직은 결제 처리를 간소화하고, 인프라 비용을 줄이고, 데이터에 대한 접근성과 다른 부서 간의 협업을 개선할 수 있습니다. 또한 클라우드 시스템은 기존의 의료 기술과의 통합이 용이하며, 보안 기능을 강화하고 데이터 보호 규정을 준수할 수 있습니다.
높은 도입 비용
의료 결제 관리 솔루션은 소프트웨어 개발, 사용자 정의, 교육, 인프라 설정 등의 요인으로 인해 도입 비용이 높습니다. 정교한 인력에 많은 투자가 필요합니다.이 경제적 장벽은 시장 성장을 방해하고 의료 제공업체는 이러한 솔루션의 도입을 늦추거나 피할 수 있으므로 전반적인 도입률에 영향을 미치고 고급 청구 관리 시스템의 보급을 늦추고 있습니다.
COVID-19의 대유행은 헬스케어 청구 관리 솔루션 시장에 큰 영향을 주어 디지털화·자동화 솔루션의 채용을 가속화 했습니다. 합리화를 위해 AI, 머신러닝, 클라우드 시스템 등의 선진기술에 대한 투자를 촉구했습니다. 또한, 유행으로 인해 업무 효율성 개선, 에러 절감, 신속한 환불 확보에 주목이 높아 시장 성장의 원동력이 되었습니다.
예측 기간 동안 라이선스가 부여된 기업용 솔루션 부문이 최대가 될 전망
라이선스 엔터프라이즈 솔루션 분야는 예측 기간 동안 최대 시장 점유율을 차지할 것으로 예상됩니다. 이러한 솔루션은 결제, 코딩, 검증, 결정, 결제 추적 등 엔드 투 엔드 결제 처리를 제공합니다.
예측기간 동안 청구결제분야의 CAGR이 가장 높아질 전망
예측 기간 동안 청구 결제 분야가 가장 높은 성장률을 보일 것으로 예상됩니다. 이러한 솔루션은 AI, 머신러닝 및 데이터 분석을 활용하여 환자의 세부 사항을 확인하고, 청구를 확인하고, 불법을 감지하며, 규정 준수를 보장합니다.
예측 기간 동안 효율적이고 비용 효율적인 헬스케어 서비스에 대한 수요가 높아지고 있기 때문에 아시아태평양이 최대 시장 점유율을 차지할 것으로 예상됩니다.
예측 기간 동안 북미가 가장 높은 CAGR을 나타낼 것으로 예상됩니다. AI를 활용한 청구 처리, 밸류 기반의 케어 모델 등에 의해 시장을 독점하고 있습니다.
According to Stratistics MRC, the Global Healthcare Claims Management Solutions Market is accounted for $16.28 billion in 2025 and is expected to reach $23.94 billion by 2032 growing at a CAGR of 6.7% during the forecast period. Healthcare claims management solutions refer to systems and processes designed to streamline and automate the handling of healthcare claims. These solutions help healthcare providers, insurance companies, and third-party administrators efficiently process, validate, and adjudicate claims for medical services. They aim to reduce administrative costs, ensure accurate reimbursement, improve compliance with regulations, and enhance customer satisfaction.
According to a Flexera study from 2021, 93% of organizations are using cloud-based technology, with 73% seeking to optimize their present cloud utilization for cost savings.
Increasing health insurance penetration
Increasing health insurance penetration leads to a higher volume of claims that healthcare providers and insurers must process efficiently. As more individuals gain health coverage, the complexity and frequency of claims management rise, creating a need for advanced solutions to handle large datasets and diverse claims types. Healthcare organizations require robust systems to ensure accurate billing, timely reimbursements, and compliance with regulations. Consequently, greater health insurance penetration directly boosts the growth of the claims management solutions market.
Data privacy concerns
Data privacy concerns in healthcare claims management solutions arise due to the sensitive nature of patient health information and the need for strict compliance with data protection regulations like HIPAA and GDPR. Inadequate security measures can lead to breaches, exposing personal and medical data. These privacy concerns often require significant investment in cybersecurity and compliance protocols, increasing costs for healthcare organizations and hindering the widespread adoption of claims management solutions, thus hampering market growth.
Growing demand for cloud-based healthcare solutions
Cloud-based solutions allow healthcare organizations to streamline claims processing, reduce infrastructure costs, and improve data accessibility and collaboration across different departments. These platforms offer real-time updates, enhancing efficiency and accuracy in claims management. Additionally, cloud-based systems are easier to integrate with existing healthcare technologies, providing enhanced security features and compliance with data protection regulations. As healthcare providers increasingly adopt cloud solutions, the demand for advanced claims management systems continues to grow.
High implementation costs
Healthcare claims management solutions have high implementation costs due to factors like software development, customization, training, and infrastructure setup. These systems require significant investment in technology and skilled personnel to ensure smooth integration with existing healthcare IT systems. This financial barrier hampers market growth, as healthcare providers may delay or avoid implementing these solutions, affecting the overall adoption rate and slowing down the widespread implementation of advanced claims management systems.
The covid-19 pandemic significantly impacted the healthcare claims management solutions market, accelerating the adoption of digital and automated solutions. The surge in healthcare claims, coupled with the need for remote processing, prompted healthcare providers to invest in advanced technologies like AI, machine learning, and cloud-based systems to streamline claim management. Additionally, the pandemic heightened the focus on improving operational efficiency, reducing errors, and ensuring quicker reimbursements, thus driving market growth.
The licensed enterprise solutions segment is expected to be the largest during the forecast period
The licensed enterprise solutions segment is expected to account for the largest market share during the forecast period. Licensed Enterprise Solutions in Healthcare Claims Management are software solutions purchased or subscribed to by healthcare organizations for in-house deployment. These solutions provide end-to-end claims processing, including billing, coding, verification, adjudication, and payment tracking. They help hospitals, insurance companies, and third-party administrators manage claims efficiently, reduce errors, ensure compliance with regulations, and accelerate reimbursements.
The claim settlement segment is expected to have the highest CAGR during the forecast period
Over the forecast period, the claim settlement segment is predicted to witness the highest growth rate. Healthcare Claims Management Solutions play a crucial role in claim settlement applications by automating and streamlining the entire process, from claim submission to final reimbursement. These solutions utilize AI, machine learning, and data analytics to verify patient details, validate claims, detect fraud, and ensure compliance with regulations. By reducing manual errors and processing times, they enhance accuracy, efficiency, and transparency in settlements.
During the forecast period, the Asia Pacific region is expected to hold the largest market share, due to the increasing demand for efficient and cost-effective healthcare services. Rising healthcare expenditures, the growing number of insured individuals, and advancements in digital health technologies are key drivers. The market is also influenced by government initiatives for healthcare reforms and the adoption of cloud-based solutions.
Over the forecast period, the North America region is anticipated to exhibit the highest CAGR, due to increasing healthcare costs, stringent regulatory requirements, and the shift toward digital healthcare solutions. The U.S. dominates the market, driven by widespread adoption of electronic health records (EHRs), AI-driven claims processing, and value-based care models. Government initiatives like HIPAA compliance and ICD-10 implementation further boost demand.
Key players in the market
Some of the key players in Healthcare Claims Management Solutions Market include McKesson Corporation, IBM, The SSI Group, Inc., Accenture Plc, Quest Diagnostics, Cegedim, Kareo, GeBBS Healthcare Solutions, Optum, Inc., Conduent, Conifer Health Solutions, Genpact, CareCloud, Cognizant Technology Solutions Corporation, eClinicalWorks, Plexis Healthcare Systems, athenahealth, Oracle Corporation, Cerner Corporation and Allscripts Healthcare Solutions Inc.
In April 2023, Conifer Health Solutions partnered with Welldoc to launch Conifer Connect, a digital health platform designed to enhance healthcare claims management and patient care. This solution integrates data analytics and AI to optimize reimbursement processes and improve financial outcomes for providers.
In October 2021, The SSI Group collaborated with RCxRules to launch an advanced automated billing solution designed to enhance healthcare organizations' financial performance. This partnership integrated RCxRules' AI-driven billing automation with The SSI Group's revenue cycle management solutions, ensuring improved accuracy in claims processing and reimbursement.