Medical Claims Processing Services in the US - Market Research Report (2014-2029)
New York, United States
Last Updated: September 2024
NAICS OD4792Revenue
$5.4bn
Past 5-Year Growth
Profit
$XXX.Xm
Employees
12,178
Businesses
2,852
Wages
$XXX.Xm
Medical Claims Processing Services in the US industry analysis
Demographic and economic factors are the driving forces behind the rising number of medical claims submitted annually. An aging population's expanding medical needs are increasing the cost and complexity of claims while rising incomes and broader insurance coverage facilitate more visits to healthcare providers. Medical claims processing companies had to adapt quickly to the changes brought on by the pandemic. Swift regulatory changes created challenges for claims processing. Yet, other pandemic effects, like labor shortages, have benefited companies as healthcare providers outsource to alleviate burdens on their workforce. However, recession concerns and inflation pressures will restrict healthcare expenditure growth in 2024, limiting the volume of claims. In all, industry-wide revenue has been growing at a CAGR of 3.0% to $5.4 billion over the past five years, including an expected jump of 1.0% in 2024 alone.
Trends and Insights
- Economic and demographic forces are increasing the volume of medical claims. Expanding medical needs of an aging population push more healthcare providers to outsource costly and complex medical claims.
- More healthcare providers are outsourcing the medical claims process. Labor shortages and rising costs are pressuring providers to use third-party claims companies to relieve some burden.
- Where medical claims processing companies operate is becoming less influential. An increasingly digital medical claims process and popularity of remote work allow processing companies to move away from clients.
- Incumbent medical claims processors benefit from established reputations. Healthcare providers rely on a series of efficient and accurate claims to receive the correct payment.
Industry Overview
Market size and recent performance (2014-2029)
Industry revenue has grown at a CAGR of 3.0 % over the past five years, to reach an estimated $5.4bn in 2024.
Trends and Insights
Rising healthcare spending translates into more medical claims
- Economic and demographic forces have been fueling rising spending on healthcare in recent years, increasing the dependence on medical claims processing services companies.
- Additional trends and insights available with purchase
Source: IBISWorld
Industry outlook (2024-2029)
Market size is projected to grow over the next five years.
Trends and Insights
Demographic trends behind a rising volume of medical claims
- Demographic and economic forces will continue driving healthcare consumption, leading the volume of medical claims to accelerate moving forward.
Biggest companies in the Medical Claims Processing Services in the US
| Company | Market Share (%)
2024 | Revenue ($m)
2024 | Profit ($m)
2024 | Profit Margin (%)
2024 |
|---|---|---|---|---|
Hms Holdings Corp. | 760.2 | 111.3 | 14.6 | |
Aon Plc | 322.2 | 98.0 | 30.4 |
To view the market share and analysis for all 2 top companies in this industry, view purchase options.
Products & Services Segmentation
Source: IBISWorld
Industry revenue is measured across several distinct product and services lines, including Policy and claims examinations, Claims investigations and Back office, administrative support and consulting. Policy and claims examinations is the largest segment of the Medical Claims Processing Services in the US.
Trends and Insights
An aging population's growing medical needs strengthen demand for claims processing
- Claims processing includes the administrative and financial procedures for submitting, reviewing and reimbursing medical claims. Claims processing is the primary service of medical claims processing providers.
- More insights available in the full report
Widen you competitive advantage with related industries
Competitors
- Insurance Brokers & Agencies in the US
- Third-Party Administrators & Insurance Claims Adjusters in the US
Complementors
- Life Insurance & Annuities in the US
- Health & Medical Insurance in the US
International industries
- Insurance Brokerage in Australia
- Insurance Brokerage in New Zealand
- Risk & Damage Evaluation in the UK
- Insurance Brokers & Adjusters in China
Table of Contents
About this industry
Industry definition
The Medical Claims Processing Services industry processes and administers medical insurance policies and claims. Businesses help doctors and other healthcare providers collect payments from insurance companies and Medicare.
What's included in this industry?
Medical insurance claims submissionsMedical claims examinationsMedical insurance claims examinationsConsulting servicesCompanies
Hms Holdings Corp.Aon PlcPurchase this report to view all 2 major companies in this industry.
Related Terms
MEDICAREMEDICAIDPATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA)Industry Code
NAICS 52429 - Medical Claims Processing Services in the US
Performance
Get an indication of the industry's health through historical, current and forward-looking trends in the performance indicators that make or break businesses.
Analyst insights
Economic and demographic forces are increasing the volume of medical claims. Expanding medical needs of an aging population push more healthcare providers to outsource costly...
In this chapter (4)
- Current Performance
- Outlook
- Volatility
- Life Cycle
Key metrics
- Annual Revenue, Recent Growth, Forecast, Revenue Volatility
- Number of Employees, Recent Growth, Forecast, Employees per Business, Revenue per Employee
- Number of Businesses, Recent Growth, Forecast, Employees per Business, Revenue per Business
- Total Profit, Profit Margin, Profit per Business
Charts
- Revenue, including historical (2014-2023) and forecast (2024-2029)
- Employees, including historical (2014-2023) and forecast (2024-2029)
- Businesses, including historical (2014-2023) and forecast (2024-2029)
- Profit, including historical (2014-2024)
- Industry Volatility vs. Revenue Growth
- Industry Life Cycle
Detailed analysis
- Trends in supply, demand and current events that are driving current industry performance
- Expected trends, economic factors and ongoing events that drive the industry's outlook
- Key success factors for businesses to overcome volatility
- How contribution to GDP, industry saturation, innovation, consolidation, and technology and systems influence the industry's life cycle phase.
Products and Markets
Learn about an industry's products and services, markets and trends in international trade.
Analyst insight
More healthcare providers are outsourcing the medical claims process. Labor shortages and rising costs are pressuring providers to use third-party claims companies to relieve...
In this chapter
- Products & Services
- Major Markets
Key metrics
- Largest market segment and value in 2024
- Product innovation level
Charts
- Products & services segmentation in 2024
- Major market segmentation in 2024
Detailed analysis
- Trends impacting the recent performance of the industry's various segments
- Innovations in the industry's product or service offering, specialization or delivery method
- Key factors that successful businesses consider in their offerings
- Buying segments and key trends influencing demand for industry products and services
Geographic Breakdown
Discover where business activity is most concentrated in an industry and the factors driving these trends to find opportunities and conduct regional benchmarking.
Analyst insights
Where medical claims processing companies operate is becoming less influential. An increasingly digital medical claims process and popularity of remote work allow processing ...
In this chapter (1)
- Business Locations
Charts
- Share of revenue, establishment, wages and employment in each state
- Share of population compared to establishments in each region in 2024
Tables
- Number and share of establishments in each state in 2024
- Number and share of revenue each state accounts for in 2024
- Number and share of wages each state accounts for in 2024
- Number and share of employees in each state in 2024
Detailed analysis
- Geographic spread of the industry across North America, and trends associated with changes in the business landscape
- Key success factors for businesses to use location to their advantage
Competitive Forces
Get data and insights on what's driving competition in an industry and the challenges industry operators and new entrants may face, with analysis built around Porter's Five Forces framework.
Analyst insights
Incumbent medical claims processors benefit from established reputations. Healthcare providers rely on a series of efficient and accurate claims to receive the correct paymen...
In this chapter (4)
- Concentration
- Barriers to Entry
- Substitutes
- Buyer & Supplier Analysis
Key metrics
- Industry concentration level
- Industry competition level and trend
- Barriers to entry level and trend
- Substitutes level and trend
- Buyer power level and trend
- Supplier power level and trend
Charts
- Market share concentration among the top 4 suppliers from 2019-2024
- Supply chain including upstream supplying industries and downstream buying industries, flow chart
Detailed analysis
- Factors impacting the industry’s level of concentration, such as business distribution, new entrants, or merger and acquisition activity.
- Key success factors for businesses to manage the competitive environment of the industry.
- Challenges that potential industry entrants face such as legal, start-up costs, differentiation, labor/capital intensity and capital expenses.
- Key success factors for potential entrants to overcome barriers to entry.
- Competitive threats from potential substitutes for the industry’s own products and services.
- Key success factors for how successful businesses can compete with substitutes.
- Advantages that buyers have to keep favorable purchasing conditions.
- Advantages that suppliers have to maintain favorable selling conditions.
- Key success factors for how businesses can navigate buyer and supplier power.
Companies
Learn about the performance of the top companies in the industry.
Analyst insights
HMS Holdings is the largest medical claims processing services company in the industry. HMS’s strong performance in recent years led to its acquisition by Gainwell Technologi...
In this chapter
- Market Share Concentration
- Companies
- Company Spotlights
Charts
- Industry market share by company in 2020 through 2024
- Major companies in the industry, including market share, revenue, profit and profit margin in 2024
- Overview of Hms Holdings Corp.'s performance by revenue, market share and profit margin from 2018 through 2024
- Overview of Aon Plc's performance by revenue, market share and profit margin from 2018 through 2024
Detailed analysis
- Description and key data for Hms Holdings Corp., and factors influencing its performance in the industry
- Description and key data for Aon Plc, and factors influencing its performance in the industry
External Environment
Understand the demographic, economic and regulatory factors that shape how businesses in an industry perform.
Analyst insights
Medical claims processors' connection to private healthcare data adds regulatory requirements. Medical claims processing companies must follow a stringent and complicated net...
In this chapter
- External Drivers
- Regulation & Policy
- Assistance
Key metrics
- Regulation & policy level and trend
- Assistance level and trend
Charts
- Regulation & Policy historical data and forecast (2014-2029)
- Assistance historical data and forecast (2014-2029)
Detailed analysis
- Demographic and macroeconomic factors influencing the industry, including Regulation & Policy and Assistance
- Major types of regulations, regulatory bodies, industry standards or specific regulations impacting requirements for industry operators
- Key governmental and non-governmental groups or policies that may provide some relief for industry operators.
Financial Benchmarks
View average costs for industry operators and compare financial data against an industry's financial benchmarks over time.
Analyst insights
Shortages of staff in the health sector are pressuring wage costs for medical claims processors. New entrants into the industry are increasing competition for an already smal...
In this chapter
- Cost Structure
- Financial Ratios
- Key Ratios
Key metrics
- Profit margin, and how it compares to the sector-wide margin
- Average wages, and how it compares to the sector-wide average wage
- Largest cost component as a percentage of revenue
- Industry average ratios for days' receivables, industry coverage and debt-to-net-worth ratio
Charts
- Average industry operating costs as a share of revenue, including purchases, wages, depreciation, utilities, rent, other costs and profit in 2024
- Average sector operating costs as a share of revenue, including purchases, wages, depreciation, utilities, rent, other costs and profit in 2024
- Investment vs. share of economy
Data tables
- Industry Multiples (2017-2022)
- Industry Tax Structure (2017-2022)
- Income Statement (2017-2022)
- Balance Sheet (2017-2022)
- Liquidity Ratios (2017-2022)
- Coverage Ratios (2017-2022)
- Leverage Ratios (2017-2022)
- Operating Ratios (2017-2022)
- Cash Flow & Debt Service Ratios (2014-2029)
- Revenue per Employee (2014-2029)
- Revenue per Enterprise (2014-2029)
- Employees per Establishment (2014-2029)
- Employees per Enterprise (2014-2029)
- Average Wage (2014-2029)
- Wages/Revenue (2014-2029)
- Establishments per Enterprise (2014-2029)
- IVA/Revenue (2014-2029)
- Imports/Demand (2014-2029)
- Exports/Revenue (2014-2029)
Detailed analysis
- Trends in the cost component for industry operators and their impact on industry costs and profitability
Key Statistics
Industry Data
Data Tables
Including values and annual change:
- Revenue (2014-2029)
- IVA (2014-2029)
- Establishments (2014-2029)
- Enterprises (2014-2029)
- Employment (2014-2029)
- Exports (2014-2029)
- Imports (2014-2029)
- Wages (2014-2029)
Methodology
How are IBISWorld reports created?
IBISWorld has been a leading provider of trusted industry research for over 50 years to the most successful companies worldwide. With offices in Australia, the United States, the United Kingdom, Germany and China, we are proud to have local teams of analysts that conduct research, data analysis and forecasting to produce data-driven industry reports.
Our analysts start with official, verified and publicly available sources of data to build the most accurate picture of each industry. Analysts then leverage their expertise and knowledge of the local markets to synthesize trends into digestible content for IBISWorld readers. Finally, each report is reviewed by one of IBISWorld’s editors, who provide quality assurance to ensure accuracy and readability.
IBISWorld relies on human-verified data and human-written analysis to compile each standard industry report. We do not use generative AI tools to write insights, although members can choose to leverage AI-based tools within the platform to generate additional analysis formats.
What data sources do IBISWorld analysts use?
Each industry report incorporates data and research from government databases, industry-specific sources, industry contacts, and our own proprietary database of statistics and analysis to provide balanced, independent and accurate insights.
Key data sources in the US include:
- US Census Bureau
- US Bureau of Labor Statistics
- US International Trade Commission
Analysts also use industry specific sources to complement catch-all sources, although their perspective may focus on a particular organization or representative body, rather than a clear overview of all industry operations. However, when balanced against other perspectives, industry-specific sources provide insights into industry trends.
These sources include:
- Industry and trade associations
- Industry federations or regulators
- Major industry players annual or quarterly filings
Finally, IBISWorld’s global data scientists maintain a proprietary database of macroeconomic and demand drivers, which our analysts use to help inform industry data and trends. They also maintain a database of statistics and analysis on thousands of industries, which has been built over our more than 50-year history and offers comprehensive insights into long-term trends.
How does IBISWorld forecast its data?
IBISWorld’s analysts and data scientists use the sources above to create forecasts for our proprietary datasets and industry statistics. Depending on the dataset, they may use regression analysis, multivariate analysis, time-series analysis or exponential smoothing techniques to project future data for the industry or driver. Additionally, analysts will leverage their local knowledge of industry operating and regulatory conditions to impart their best judgment on the forecast model.
IBISWorld prides itself on being a trusted, independent source of data, with over 50 years of experience building and maintaining rich datasets and forecasting tools. We are proud to be the keystone source of industry information for thousands of companies across the world.
Learn more about our methodology and data sourcing on the Help Center.
Frequently Asked Questions
Unlock comprehensive answers and precise data upon purchase. View purchase options.
What is the market size of the Medical Claims Processing Services in the US industry in United States in 2024?
The market size of the Medical Claims Processing Services in the US industry in United States is $5.4bn in 2024.
How many businesses are there in the Medical Claims Processing Services in the US industry in 2024?
There are 2,852 businesses in the Medical Claims Processing Services in the US industry in United States, which has grown at a CAGR of 5.8 % between 2019 and 2024.
Has the Medical Claims Processing Services in the US industry in United States grown or declined over the past 5 years?
The market size of the Medical Claims Processing Services in the US industry in United States has been growing at a CAGR of 3.0 % between 2019 and 2024.
What is the forecast growth of the Medical Claims Processing Services in the US industry in United States over the next 5 years?
Over the next five years, the Medical Claims Processing Services in the US industry in United States is expected to grow.
What are the biggest companies in the Medical Claims Processing Services in the US market in United States?
The biggest companies operating in the Medical Claims Processing Services market in United States are Hms Holdings Corp. and Aon Plc
What does the Medical Claims Processing Services in the US in United States include?
Medical insurance claims submissions and Medical claims examinations are part of the Medical Claims Processing Services in the US industry.
Which companies have the highest market share in the Medical Claims Processing Services in the US in United States?
The company holding the most market share in United States is Hms Holdings Corp..
How competitive is the Medical Claims Processing Services in the US industry in United States?
The level of competition is high and increasing in the Medical Claims Processing Services in the US industry in United States.
