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市場調查報告書
商品編碼
2040827

美國醫療保險公司核心業務流程解決方案市場：市場規模、佔有率和趨勢分析（按類型、部署方式和地區分類），細分市場預測（2026-2033 年）

U.S. Healthcare Payers Core Administrative Processing Solutions Market Size, Share & Trends Analysis Report By Type (Software, Services), By Deployment (On-premise, Cloud-based), By Region, And Segment Forecasts, 2026 - 2033
出版日期: | 出版商: Grand View Research | 英文 90 Pages | 商品交期: 2-10個工作天內

價格

美國健康保險公司核心業務流程解決方案市場概況

據估計，2025 年美國健康保險公司核心業務處理解決方案市值為 20 億美元，預計到 2033 年將達到 36 億美元。

預計從 2026 年到 2033 年，該市場將以 7.5% 的複合年成長率成長。推動市場成長的因素包括：降低成本的需求不斷成長、技術進步、註冊和計費流程的現代化、市場參與者更多地採用策略舉措，以及不斷變化的監管和合規要求。

美國醫療保險公司核心業務流程解決方案產業的註冊和計費流程現代化正顯著推動市場成長。透過利用先進技術和精簡的系統，醫療保險公司能夠有效率地註冊新用戶、確保計費準確並最佳化收入週期管理。這項轉型提高了營運效率，同時提升了服務質量，最終提高了客戶滿意度和客戶維繫。新一代核心管理處理解決方案 (CAPS) 提供先進的功能，可增強營運效率並改善用戶服務。這些功能為各種規模的醫療保險計劃帶來巨大價值，支持其發展和適應能力。

  • 採用混合雲端模式提供。
  • 適合企業使用的配置
  • 高度適應性強、技術領先的架構
  • 支持基於價值的模型
  • 無縫生態系整合

此外，透過在投保和理賠處理中實施創新解決方案和最佳實踐，保險公司可以增強自身競爭力並實現永續的財務表現。例如，健康保險公司正擴大採用人工智慧驅動的理賠和理賠處理自動化技術，先進的實施方案可以將人事費用降低約35%，並將拒賠率降低30-40%，從而提高整體準確性、效率和收入周期績效。

此外，人工智慧的快速發展正吸引著醫療產業領導者的關注，包括健康保險計劃高管、解決方案供應商和學術界，他們都在關注人工智慧對醫療保健營運的潛在影響。健康保險公司正在將人工智慧整合到其核心行政處理系統中，旨在提高自動審核率、簡化預核准流程並防止詐欺、浪費和濫用。

美國國家經濟研究局 (NBER) 於 2023 年 1 月發布的一項研究表明，人工智慧在醫療保健領域的廣泛應用可將美國醫療保健成本降低 5% 至 10%，每年節省約 2000 億至 3600 億美元。研究指出，理賠管理、用戶服務和企業職能是人工智慧可以大幅降低醫療保險支付方管理成本的關鍵領域。

目錄

第1章：分析方法和範圍

第2章執行摘要

第3章：美國健康保險提供者核心業務流程解決方案市場：影響因素、趨勢與範圍

  • 市場歷史及展望
  • 技術展望
  • 法律規範
  • 市場動態
  • 美國醫療保險公司核心業務流程解決方案市場分析工具
  • 案例研究與見解

第4章：美國健康保險提供者核心業務流程解決方案市場：按類型分類的估算與趨勢分析

  • 市場佔有率分析：按類型分類（2025 年和 2033 年）
  • 美國健康保險提供者核心業務流程解決方案市場：按類型分類（2021-2033 年）
  • 軟體
    • 融合的
    • 獨立版

第5章：美國健康保險提供者核心業務流程解決方案市場：按部署方式分類的估算與趨勢分析

  • 市佔率分析：依部署方式分類（2025 年及 2033 年）
  • 美國健康保險提供者核心業務流程解決方案市場：按部署方式分類（2021-2033 年）
  • 現場
  • 基於雲端的

第6章 競爭情勢

  • 近期趨勢及影響分析：依主要市場參與企業
  • 公司分類
  • 企業市場占有率分析（2025 年）
  • 企業熱力圖分析
  • 策略規劃
  • 公司簡介
    • HealthEdge Software, Inc.
    • Optum
    • Cognizant
    • HealthAxis
    • Plexis Healthcare Systems
    • Mphasis
    • SS&C Technologies
    • Conduent
    • RAM Technologies
    • Evolent
    • Invidasys
    • Advantasure
    • VBA solftware
    • Advalent Corp
Product Code: GVR-4-68040-304-0

U.S. Healthcare Payers Core Administrative Processing Solutions Market Summary

The U.S. healthcare payers core administrative processing solutions market size was estimated at USD 2.0 billion in 2025 and is projected to reach USD 3.6 billion by 2033, growing at a CAGR of 7.5% from 2026 to 2033. The market growth is attributed to the growing demand for cost reduction, technological advancements, the modernization of enrollment and billing processes, the increasing adoption of strategic initiatives by market players, and evolving regulatory and compliance requirements.

Modernizing enrollment and billing processes in the U.S. healthcare payers core administrative processing solutions industry is significantly contributing to market growth. By leveraging advanced technologies and streamlined systems, healthcare payers can efficiently onboard new members, ensure accurate billing, and optimize revenue cycle management. This transformation enhances operational efficiency while improving service quality, ultimately driving customer satisfaction and retention. Next-generation core administrative processing solutions (CAPS) provide advanced capabilities that enhance operational efficiency and improve member services. These capabilities deliver significant value to health plans of all sizes, supporting growth and adaptability.

  • Hybrid Cloud Delivery
  • Business-Friendly Configuration
  • Adaptable Modern Architecture
  • Ready for Value-Based Models
  • Seamless Ecosystem Integration

Moreover, the adoption of innovative solutions and best practices in enrollment and billing enables payers to strengthen their competitive positioning and achieve sustainable financial performance. For instance, healthcare payers are increasingly adopting AI-driven automation in billing and claims processing, which can reduce labor costs by approximately 35% and lower denial rates by 30-40% in advanced implementations, thereby improving overall accuracy, efficiency, and revenue cycle performance.

Furthermore, the increasing advancements in artificial intelligence have captured the attention of healthcare industry leaders, including health plan executives, solution providers, and academia, regarding its potential effects on healthcare operations. Health payers are implementing AI within core administration processing systems to enhance auto-adjudication rates, streamline prior authorization processes, and mitigate fraud, waste, and abuse.

A study published by the National Bureau of Economic Research in January 2023 found that the broader adoption of AI in healthcare reduces U.S. healthcare expenditures by 5 to 10 percent, translating into annual savings of approximately USD 200 billion to USD 360 billion. The research identifies claims management, member services, and corporate functions as key areas where AI could significantly reduce administrative costs for healthcare payers.

U.S. Healthcare Payers Core Administrative Processing Solutions Market Report Segmentation

This report forecasts revenue growth at the country level and provides an analysis of the latest industry trends in each of the sub-segments from 2021 to 2033. For this study, Grand View Research has segmented the U.S. healthcare payers core administrative processing solutions market report based on type, and deployment.

  • Type Outlook (Revenue, USD Million, 2021 - 2033)
  • Software
    • Standalone
    • Integrated
  • Services
  • Deployment Outlook (Revenue, USD Million, 2021 - 2033)
  • On-premise
  • Cloud-based

Table of Contents

Chapter 1. Methodology and Scope

  • 1.1. Market Segmentation and Scope
  • 1.2. Market Definitions
  • 1.3. Research Methodology
  • 1.4. Information Procurement
    • 1.4.1. Purchased Database
    • 1.4.2. GVR's Internal Database
  • 1.5. Details of primary research
  • 1.6. Market Formulation & Validation
  • 1.7. Model Details
    • 1.7.1. Commodity flow analysis (Model 1)
      • 1.7.1.1. Approach 1: Commodity flow approach
    • 1.7.2. Volume price analysis (Model 2)
      • 1.7.2.1. Approach 2: Volume price analysis
  • 1.8. Research Scope and Assumptions
    • 1.8.1. List of Secondary Sources
    • 1.8.2. List of Primary Sources
    • 1.8.3. Objectives

Chapter 2. Executive Summary

  • 2.1. Market Outlook
  • 2.2. Segment Outlook
    • 2.2.1. Type Outlook
    • 2.2.2. Deployment Outlook
  • 2.3. Competitive Insights

Chapter 3. U.S. Healthcare Payers Core Administrative Processing Solutions Market Variables, Trends, & Scope

  • 3.1. Market Lineage Outlook
    • 3.1.1. Parent Market Outlook
    • 3.1.2. Related/Ancillary Market Outlook
  • 3.2. Technology Outlook
  • 3.3. Regulatory Framework
  • 3.4. Market Dynamics
    • 3.4.1. Market Drivers Analysis
      • 3.4.1.1. Growing demand for cost reduction and operational efficiency
      • 3.4.1.2. Technological advancements (AI, analytics, cloud adoption)
      • 3.4.1.3. Increasing need for regulatory compliance and process modernization
    • 3.4.2. Market Restraints Analysis
      • 3.4.2.1. High implementation and maintenance costs
      • 3.4.2.2. Complexity in integration with legacy systems
      • 3.4.2.3. Resistance to change among payer organizations
    • 3.4.3. Industry Challenges
    • 3.4.4. Opportunity Analysis
  • 3.5. U.S. Healthcare Payers Core Administrative Processing Solutions Market Analysis Tools
    • 3.5.1. Porter's Analysis
      • 3.5.1.1. Bargaining power of the suppliers
      • 3.5.1.2. Bargaining power of the buyers
      • 3.5.1.3. Threats of substitution
      • 3.5.1.4. Threats from new entrants
      • 3.5.1.5. Competitive rivalry
    • 3.5.2. PESTEL Analysis
      • 3.5.2.1. Political landscape
      • 3.5.2.2. Economic and Social landscape
      • 3.5.2.3. Technological landscape
      • 3.5.2.4. Environmental landscape
      • 3.5.2.5. Legal landscape
  • 3.6. Case Study & Insights

Chapter 4. U.S. Healthcare Payers Core Administrative Processing Solutions Market: Type Estimates & Trend Analysis

  • 4.1. Definition and Scope
  • 4.2. Type Market Share Analysis, 2025 & 2033
  • 4.3. Segment Dashboard
  • 4.4. U.S. Healthcare Payers Core Administrative Processing Solutions Market: By Type, 2021 to 2033
  • 4.5. Software
    • 4.5.1. Software Market Revenue Estimates and Forecasts, 2021 - 2033 (USD Million)
    • 4.5.2. Integrated
      • 4.5.2.1. Integrated Market Revenue Estimates and Forecasts, 2021 - 2033 (USD Million)
    • 4.5.3. Standalone
      • 4.5.3.1. Standalone Market Revenue Estimates and Forecasts, 2021 - 2033 (USD Million)

Chapter 5. U.S. Healthcare Payers Core Administrative Processing Solutions Market: Deployment Estimates& Trend Analysis

  • 5.1. Definition and Scope
  • 5.2. Deployment Market Share Analysis, 2025 & 2033
  • 5.3. Segment Dashboard
  • 5.4. U.S. Healthcare Payers Core Administrative Processing Solutions Market: By Deployment, 2021 to 2033
  • 5.5. On-premise
    • 5.5.1. On-premise Market Revenue Estimates and Forecasts, 2021 - 2033 (USD Million)
  • 5.6. Cloud-based
    • 5.6.1. Cloud-based Market Revenue Estimates and Forecasts, 2021 - 2033 (USD Million)

Chapter 6. Competitive Landscape

  • 6.1. Recent Developments & Impact Analysis by Key Market Participants
  • 6.2. Company Categorization
  • 6.3. Company Market Share Analysis 2025
  • 6.4. Company Heat Map Analysis
  • 6.5. Strategy Mapping
  • 6.6. Company Profiles
    • 6.6.1. HealthEdge Software, Inc.
      • 6.6.1.1. Participant's Overview
      • 6.6.1.2. Financial Performance
      • 6.6.1.3. Product Benchmarking
      • 6.6.1.4. Recent Developments
    • 6.6.2. Optum
      • 6.6.2.1. Participant's Overview
      • 6.6.2.2. Financial Performance
      • 6.6.2.3. Product Benchmarking
      • 6.6.2.4. Recent Developments
    • 6.6.3. Cognizant
      • 6.6.3.1. Participant's Overview
      • 6.6.3.2. Financial Performance
      • 6.6.3.3. Product Benchmarking
      • 6.6.3.4. Recent Developments
    • 6.6.4. HealthAxis
      • 6.6.4.1. Participant's Overview
      • 6.6.4.2. Financial Performance
      • 6.6.4.3. Product Benchmarking
      • 6.6.4.4. Recent Developments
    • 6.6.5. Plexis Healthcare Systems
      • 6.6.5.1. Participant's Overview
      • 6.6.5.2. Financial Performance
      • 6.6.5.3. Product Benchmarking
      • 6.6.5.4. Recent Developments
    • 6.6.6. Mphasis
      • 6.6.6.1. Participant's Overview
      • 6.6.6.2. Financial Performance
      • 6.6.6.3. Product Benchmarking
      • 6.6.6.4. Recent Developments
    • 6.6.7. SS&C Technologies
      • 6.6.7.1. Participant's Overview
      • 6.6.7.2. Financial Performance
      • 6.6.7.3. Product Benchmarking
      • 6.6.7.4. Recent Developments
    • 6.6.8. Conduent
      • 6.6.8.1. Participant's Overview
      • 6.6.8.2. Financial Performance
      • 6.6.8.3. Product Benchmarking
      • 6.6.8.4. Recent Developments
    • 6.6.9. RAM Technologies
      • 6.6.9.1. Participant's Overview
      • 6.6.9.2. Financial Performance
      • 6.6.9.3. Product Benchmarking
      • 6.6.9.4. Recent Developments
    • 6.6.10. Evolent
      • 6.6.10.1. Participant's Overview
      • 6.6.10.2. Financial Performance
      • 6.6.10.3. Product Benchmarking
      • 6.6.10.4. Recent Developments
    • 6.6.11. Invidasys
      • 6.6.11.1. Participant's Overview
      • 6.6.11.2. Financial Performance
      • 6.6.11.3. Product Benchmarking
      • 6.6.11.4. Recent Developments
    • 6.6.12. Advantasure
      • 6.6.12.1. Participant's Overview
      • 6.6.12.2. Financial Performance
      • 6.6.12.3. Product Benchmarking
      • 6.6.12.4. Recent Developments
    • 6.6.13. VBA solftware
      • 6.6.13.1. Participant's Overview
      • 6.6.13.2. Financial Performance
      • 6.6.13.3. Product Benchmarking
      • 6.6.13.4. Recent Developments
    • 6.6.14. Advalent Corp
      • 6.6.14.1. Participant's Overview
      • 6.6.14.2. Financial Performance
      • 6.6.14.3. Product Benchmarking
      • 6.6.14.4. Recent Developments

List of Tables

  • Table 1 List of Secondary Sources
  • Table 2 List of Abbreviations
  • Table 3 U.S. Healthcare Payers Core Administrative Processing Solutions Market, By Type, 2021 - 2033 (USD Million)
  • Table 4 U.S. Healthcare Payers Core Administrative Processing Solutions Market, By Deployment, 2021 - 2033 (USD Million)

List of Figures

  • Fig. 1 U.S. Healthcare Payers Core Administrative Processing Solutions Market Segmentation
  • Fig. 2 Information Procurement
  • Fig. 3 Data Analysis Models
  • Fig. 4 Market Formulation and Validation
  • Fig. 5 Data Validating & Publishing
  • Fig. 6 Market Snapshot
  • Fig. 7 Segment Snapshot
  • Fig. 8 Competitive Landscape Snapshot
  • Fig. 9 U.S. Healthcare Payers Core Administrative Processing Solutions - Market Size and Growth Prospects (USD Million)
  • Fig. 10 U.S. Healthcare Payers Core Administrative Processing Solutions Market: Market Dynamics
  • Fig. 11 U.S. Healthcare Payers Core Administrative Processing Solutions Market: PORTER's Analysis
  • Fig. 12 U.S. Healthcare Payers Core Administrative Processing Solutions Market: PESTEL Analysis
  • Fig. 13 U.S. Healthcare Payers Core Administrative Processing Solutions Market Share, By Type, 2025 & 2033 (USD Million)
  • Fig. 14 U.S. Healthcare Payers Core Administrative Processing Solutions Market, By Type: Market Share, 2025 & 2033
  • Fig. 15 Software Market Estimates & Forecasts, 2021 - 2033 (Revenue, USD Billion)
  • Fig. 16 Integrated Market Estimates & Forecasts, 2021 - 2033 (Revenue, USD Billion)
  • Fig. 17 Standalone Market Estimates & Forecasts, 2021 - 2033 (Revenue, USD Billion)
  • Fig. 18 Services Market Estimates & Forecasts, 2018 - 2030 (USD Million)
  • Fig. 19 U.S. Healthcare Payers Core Administrative Processing Solutions Market, by Deployment: Key Takeaways
  • Fig. 20 U.S. Healthcare Payers Core Administrative Processing Solutions Market, by Deployment: Market Share, 2025 & 2033
  • Fig. 21 On-premise Market Estimates & Forecasts, 2021 - 2033 (Revenue, USD Billion)
  • Fig. 22 Cloud-based Market Estimates & Forecasts, 2021 - 2033 (Revenue, USD Billion)
  • Fig. 23 Key Company Categorization
  • Fig. 24 Company Market Positioning
  • Fig. 25 Key Company Market Share Analysis, 2025
  • Fig. 26 Strategic Framework