# Healthcare Payers * **Definition:** Organizations that finance or reimburse the cost of health services, including insurance companies and government programs. * **Taxonomy:** Sectors / Healthcare Payers ## News * Selected news on the topic of **Healthcare Payers**, for healthcare technology leaders * 28.2K news items are in the system for this topic * Posts have been filtered for tech-related keywords | Date | Title | Source | | --- | --- | --- | | 2/21/2025 | [**Eli Lilly bets big on weight-loss pill with $550M inventory stockpile - HealthLeaders Media**](https://www.healthleadersmedia.com/pharma/eli-lilly-bets-big-weight-loss-pill-550m-inventory-stockpile) | [[HealthLeaders Media]] | | 1/5/2025 | [**Three ways payers and providers can improve risk adjustment - Viewpoint**](https://www.chiefhealthcareexecutive.com/view/three-ways-payers-and-providers-can-improve-risk-adjustment-viewpoint) | [[Chief Healthcare Executive]] | | 12/28/2024 | [**Expanded data sharing in healthcare: Three real-world considerations - Viewpoint**](https://www.chiefhealthcareexecutive.com/view/expanded-data-sharing-in-healthcare-three-real-world-considerations-viewpoint) | [[Chief Healthcare Executive]] | | 12/11/2024 | [**Generative AI: Transforming Healthcare Payers from Cost Centers to Value Creators**](https://blogs.perficient.com/2024/12/11/generative-ai-transforming-healthcare-payers-from-cost-centers-to-value-creators/) | [[Perficient Healthcare]] | | 12/10/2024 | [**4 Cornerstones for Successful AI Implementation in Hospital Revenue Cycle Management in 2025**](https://hitconsultant.net/2024/12/10/4-cornerstones-for-successful-ai-implementation-in-hospital-revenue-cycle-management/) | [[HIT Consultant]] | | 11/14/2024 | [**Abacus Insights Expands CMS Interoperability Data Solution Suite to Accelerate Payer Readiness to Meet Complex CMS-0057-F Government Mandates Starting in January 2026**](http://www.businesswire.com/news/home/20241114792225/en/Abacus-Insights-Expands-CMS-Interoperability-Data-Solution-Suite-to-Accelerate-Payer-Readiness-to-Meet-Complex-CMS-0057-F-Government-Mandates-Starting-in-January-2026/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 11/14/2024 | [**Abacus Insights Expands CMS Interoperability Data Solution Suite to Accelerate Payer Readiness to Meet Complex CMS-0057-F Government Mandates Starting in January 2026**](http://www.businesswire.com/news/home/20241114792225/en/Abacus-Insights-Expands-CMS-Interoperability-Data-Solution-Suite-to-Accelerate-Payer-Readiness-to-Meet-Complex-CMS-0057-F-Government-Mandates-Starting-in-January-2026/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 11/14/2024 | [**Abacus Insights Expands CMS Interoperability Data Solution Suite to Accelerate Payer ...**](https://www.businesswire.com/news/home/20241114792225/en/Abacus-Insights-Expands-CMS-Interoperability-Data-Solution-Suite-to-Accelerate-Payer-Readiness-to-Meet-Complex-CMS-0057-F-Government-Mandates-Starting-in-January-2026) | [[Business Wire]] | | 11/13/2024 | [**Abacus Insights Expands CMS Interoperability Data Solution Suite to Accelerate Payer Readiness to Meet Complex CMS-0057-F Government Mandates Starting in January 2026**](https://www.businesswire.com/news/home/20241114792225/en/Abacus-Insights-Expands-CMS-Interoperability-Data-Solution-Suite-to-Accelerate-Payer-Readiness-to-Meet-Complex-CMS-0057-F-Government-Mandates-Starting-in-January-2026/) | [[Business Wire]] | | 11/11/2024 | [**Healthcare Cloud Computing Market to Grow by USD 98.6 Billion from 2024-2028, as Integrated Services Drive Demand with AI-Powered Market Evolution - Technavio**](https://www.prnewswire.com/news-releases/healthcare-cloud-computing-market-to-grow-by-usd-98-6-billion-from-2024-2028--as-integrated-services-drive-demand-with-ai-powered-market-evolution---technavio-302300785.html) | [[PR Newswire]] | | 9/26/2024 | [**Providers and payers ramp up investments in cybersecurity, AI in 2024**](https://www.fiercehealthcare.com/health-tech/klas-providers-and-payers-invested-cybersecurity-ai-2024) | [[FierceHealthcare]] | | 9/23/2024 | [**Finance leaders balance AI investment to expected ROI**](https://www.healthcarefinancenews.com/news/finance-leaders-balance-ai-investment-expected-roi) | [[Healthcare Finance]] | | 9/17/2024 | [**Providers and Payers Are Increasing Their Tech Spend - Where Are They Investing the Most?**](https://medcitynews.com/2024/09/healthcare-technology/) | [[MedCity News]] | | 9/17/2024 | [**US healthcare spending more on AI, cybersecurity, other IT investments-- Bain and KLAS Research**](https://www.tmcnet.com/usubmit/2024/09/17/10074078.htm) | tmcnet.com | | 9/17/2024 | [**Survey: Payers, Providers Boosting IT Investments - Healthcare Innovation**](https://www.hcinnovationgroup.com/finance-revenue-cycle/health-it-market/news/55140397/survey-payers-providers-boosting-it-investments) | [[Healthcare Innovation]] | | 9/17/2024 | [**US healthcare spending more on AI, cybersecurity, other IT investments - Bain & Company**](https://www.bain.com/about/media-center/press-releases/2024/us-healthcare-spending-more-on-ai-cybersecurity-other-it-investments-bain--company-and-klas-research/) | bain.com | | 8/28/2024 | [**GCCs pay 20ore than IT firms**](https://www.msn.com/en-in/money/news/gccs-pay-20-more-than-it-firms/ar-AA1pBzfU) | msn.com | | 8/27/2024 | [**Inovaare cited by Gartner for the first time as a Sample Vendor within its Hype Cycle for Healthcare Payers, 2024 report**](https://www.prweb.com/releases/inovaare-cited-by-gartner-for-the-first-time-as-a-sample-vendor-within-its-hype-cycle-for-healthcare-payers-2024-report-302230123.html) | [[PRWeb]] | | 8/19/2024 | [**The Future of the Payer Industry: Join Fierce Healthcare Editors this Fall**](https://www.fiercehealthcare.com/sponsored/future-payer-industry-join-fierce-healthcare-editors-fall?itm_source=parsely-api) | [[FierceHealthcare]] | | 8/8/2024 | [**The Future of the Payer Industry: Join Fierce Healthcare Editors this Fall**](https://www.fiercehealthcare.com/sponsored/future-payer-industry-join-fierce-healthcare-editors-fall) | [[FierceHealthcare]] | | 7/29/2024 | [**Why Is There Such a Tension Between Payers & Providers and What Can Be Done About It?**](https://www.healthcareittoday.com/2024/07/29/why-is-there-such-a-tension-between-payers-providers-and-what-can-be-done-about-it/) | [[Healthcare IT Today]] | | 7/3/2024 | [**Healthcare IT Market Poised for Explosive Growth, Projected to Reach $1.83 Trillion by 2031**](https://www.whatech.com/og/markets-research/medical/851706-healthcare-it-market-poised-for-explosive-growth-projected-to-reach-1-83-trillion-by-2031) | whatech.com | | 6/24/2024 | [**Simplify Healthcare Acquires Virtical.ai, a Pioneering AI Company, Accelerating AI Integration and Innovation at Payers**](http://www.businesswire.com/news/home/20240624951019/en/Simplify-Healthcare-Acquires-Virtical.ai-a-Pioneering-AI-Company-Accelerating-AI-Integration-and-Innovation-at-Payers/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 6/24/2024 | [**Simplify Healthcare Acquires Virtical.ai, a Pioneering AI Company, Accelerating AI Integration and Innovation at Payers**](https://www.lelezard.com/en/news-21428998.html) | lelezard.com | | 6/24/2024 | [**Simplify Healthcare Acquires Virtical.ai, a Pioneering AI Company, Accelerating AI Integration and Innovation at Payers**](https://www.01net.it/simplify-healthcare-acquires-virtical-ai-a-pioneering-ai-company-accelerating-ai-integration-and-innovation-at-payers/) | 01net.it | ## Sector Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Omega Healthcare**: A provider of healthcare outsourcing services, emphasizing the importance of technology in payer solutions and value-based care. - **Simplify Healthcare**: A technology company providing advanced software solutions aimed at enhancing operational efficiency and member experience for healthcare payers. - **VirtualHealth**: Develops the HELIOS platform to streamline care management and compliance for healthcare payers. - **Change Healthcare**: A healthcare technology company that provides data and analytics-driven solutions to improve clinical and financial outcomes. - **CitiusTech**: A healthcare technology services firm that offers solutions to enhance operational efficiency for payers. - **Amazon**: A major player in the healthcare sector, expanding its operations despite projected losses, focusing on enhancing healthcare services. - **Humata Health**: A company specializing in AI-driven prior authorization solutions for healthcare providers and payers, aiming to streamline the authorization process. - **Abacus Insights**: A healthcare technology company providing data solutions to help health plans comply with CMS mandates and enhance data usability. - **mPulse**: Provider of Health Experience and Insights technology, recognized for its capabilities in health navigation and social determinants of health resource management. - **Oracle Health**: A technology company providing cloud-based solutions for healthcare, including automated claims processing. - **Itiliti Health**: Partnering with VirtualHealth to enhance prior authorization and care management processes. - **Epic Systems**: A healthcare technology company focused on developing software for healthcare organizations, including solutions for interoperability and patient engagement. - **Cotiviti**: A company focused on delivering innovative SaaS solutions to healthcare payers, recently appointed a new Chief Technology Officer to enhance its technology strategy. - **Availity**: The largest real-time health information network in the U.S., providing solutions to streamline prior authorization processes and improve healthcare interactions. - **Innova Solutions**: An Authorized Solution Partner of Simplify Healthcare, focused on implementing software solutions to transform business models for health insurance companies. - **Lyfegen**: A leader in drug rebate management technology, focusing on simplifying pricing models for payers and pharmaceutical companies. ### Partnerships and Collaborations - **Payers and Providers**: Collaboration is essential for optimizing risk adjustment processes and improving patient care, with payers assisting providers in identifying diagnosis gaps. - **Simplify Healthcare and Innova Solutions**: Partnership aimed at enhancing operational efficiency and member experience for healthcare payers. - **Simplify Healthcare and Capgemini**: A strategic partnership aimed at enhancing member experience for payers and improving operational efficiency through advanced analytics and AI. - **Simplify Healthcare and CitiusTech**: This collaboration leverages Simplify Healthcare's cloud-based software platform to provide customizable solutions that strengthen CitiusTech's offerings for payers. - **Simplify Healthcare and Virtical.ai**: The acquisition aims to combine Simplify Healthcare's cloud platform with Virtical.ai's AI technology to enhance payer operations and member engagement. - **Lyfegen**: Collaborates with over 50 healthcare organizations to streamline rebate agreements and manage drug costs. - **Humata Health and Blue Venture Fund**: Humata Health secured a $25 million investment to enhance its AI-driven prior authorization solutions, facilitating collaboration with payers. - **Abacus Insights and Onyx**: Collaboration to provide a data solution that helps health plans comply with CMS mandates. - **MultiCare Health System and Xsolis**: A pilot program for a generative AI solution to streamline documentation for appeals, improving financial relief for healthcare systems. - **Abacus Insights**: Partners with major organizations like Blue Cross Blue Shield and Prime Therapeutics to provide tailored data solutions. - **VirtualHealth and Itiliti Health**: Collaboration to launch the HELIOS + Itiliti Health platform, streamlining prior authorization and compliance. ### Innovations, Trends, and Initiatives - **Cloud Computing Adoption**: Healthcare payers are migrating to cloud solutions for scalability, cost savings, and enhanced data security. - **Value-Based Care Models**: Payers are increasingly adopting value-based care models to improve care delivery and outcomes while managing costs. - **AI Integration**: Healthcare payers are increasingly adopting AI to enhance claims processing efficiency and improve revenue cycle management. - **Growth of Healthcare Payer Services Market**: Projected to grow from USD 67.37 billion in 2023 to USD 129.16 billion by 2032, driven by operational optimization and advanced IT solutions. - **Interoperability Standards**: Payers are expected to enhance consumer experiences by meeting CMS interoperability standards, facilitating better data exchange. - **Cybersecurity Investments**: Following significant cyberattacks, both payers and providers are increasing investments in cybersecurity measures to protect sensitive data. - **Patient Engagement Solutions**: The market for patient engagement solutions is expanding as payers and providers seek to enhance healthcare consumerism through digital tools. - **AI and Machine Learning**: Increasing use of AI technologies to improve member engagement and operational efficiency in healthcare payer processes. - **Real-Time Payments**: Healthcare providers are planning to adopt real-time payments to modernize payment systems and improve operational efficiency. - **Value-Based Care (VBC)**: Payers are increasingly adopting VBC models to improve patient outcomes and reduce costs associated with chronic diseases. - **Generative AI**: Payers are exploring generative AI for proactive health enablement, with expectations of significant efficiency gains. - **AI Adoption**: The adoption of AI among payers has remained stable, with about 25% reporting established strategies, while providers have seen a rise from 5% to 15% in AI strategy implementation. - **CMS Interoperability Rule**: The Biden administration's rule aims to enhance the prior authorization process, requiring payers to provide specific reasons for denied requests. - **Data Usability Solutions**: Abacus Insights focuses on consolidating and standardizing data to enhance usability and reduce costs for payers. - **Health Navigation Solutions**: Emerging as critical tools for enhancing member experiences and streamlining healthcare interactions. - **Patient Engagement Technology**: Rapid growth in technologies aimed at enhancing healthcare consumerism, particularly in managing chronic diseases and mental health. - **Digital Care Navigation**: Utilized to improve patient outcomes and reduce costs by providing personalized strategies for managing chronic conditions. - **CMS Interoperability and Prior Authorization Final Rule**: A regulatory initiative mandating the use of digitized data and APIs to enhance interoperability and automate prior authorizations. - **Adoption of AI and Automation**: Generative AI is transforming healthcare by automating claims processing and personalizing coverage, although challenges in integration and data privacy remain. ### Challenges and Concerns - **Regulatory Compliance**: Healthcare payers must navigate evolving federal and state regulations, necessitating advanced solutions for compliance. - **Rising Healthcare Costs**: Healthcare expenses are increasing, prompting payers to seek innovative solutions to manage costs and improve member engagement. - **Rising Care Costs**: Payers face pressure to lower healthcare costs while improving quality and outcomes amidst rising care costs and regulatory scrutiny. - **Market Competition**: Payers must navigate a competitive landscape, including new entrants like Amazon, which are reshaping the healthcare market. - **Cybersecurity Risks**: Increased urgency for payers and providers to prioritize cybersecurity following incidents like the cyberattack on Change Healthcare. - **Data Interoperability**: Payers and providers face significant challenges with data interoperability, which complicates the transition to value-based care. - **Denial Management**: Healthcare leaders are increasingly facing challenges with payer denials for medically necessary services, particularly from Medicare Advantage plans. - **Regulatory Pressures**: Payers face increasing regulatory demands and rising costs, necessitating a balance between service enhancement and operational cost reduction. - **Data Security**: Payers face challenges in maintaining adequate security staffing and resources, making cloud solutions attractive for enhanced data protection. - **Legacy Technology**: Many payers struggle with outdated systems, which hinder scalability and cost management, necessitating modernization efforts. - **Disparity in AI Adoption**: A survey indicates a significant gap in AI strategy adoption between payers and providers, with only 25% of payers having established strategies. - **Claims Denials**: Healthcare systems face significant financial burdens due to denied claims, with a high cost associated with contesting these denials. - **Data Privacy and Security**: The integration of AI and direct access to EHRs raises concerns about data privacy, compliance with HIPAA, and potential unauthorized access. - **Cost and Governance Issues**: Barriers such as regulatory concerns and the need for robust governance frameworks hinder the widespread adoption of generative AI in healthcare. - **AI Misuse by Insurers**: Concerns raised regarding the potential misuse of AI by insurers to deny necessary medical care, prompting calls for human oversight in decision-making. ## Related Topics [[Healthcare Payors]]; [[Healthcare Payer Services]]; [[Healthcare Providers]]; [[AI for Healthcare Payors]]