Everest Group - Healthcare Payer Digital Services PEAK Matrix ...€¦ · This, in turn, is driving the need for research and market intelligence on demand and supply trends in healthcare

EGR-2019-45-R-3485

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®

®

™

Healthcare Payer Digital Services PEAK Matrix™ Assessment

with Service Provider Landscape 2020

Healthcare IT Services (ITS)

Market Report – December 2019

Copyright © 2019, Everest Global, Inc.

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Table of contents (page 1 of 2)

Introduction and overview 5

Summary of key messages 10

Section I: Payer digital services trends 13

⚫ Defining digital 14

⚫ A look at the payer digital services market 18

⚫ Application of digital in healthcare payer 22

Section II: PEAK Matrix™ for payer digital services 27

⚫ PEAK Matrix framework 28

⚫ PEAK Matrix for payer digital services 31

⚫ Payer digital services PEAK Matrix characteristics 32

⚫ Payer digital services PEAK Star performers 33

⚫ Summary dashboard 34

Section III: Service provider profiles 39

⚫ Accenture 40

⚫ Atos 42

⚫ Capgemini 45

⚫ CGI 48

⚫ Citius Tech 50

⚫ Cognizant 52

⚫ Conduent 55

Topic Page no.


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Table of contents (page 2 of 2)

Service provider profiles (continued)

⚫ DXC Technology 57

⚫ emids 59

⚫ EPAM 62

⚫ HCL Technologies 64

⚫ Hexaware 67

⚫ HTC Global Services 70

⚫ IBM 72

⚫ Infosys 75

⚫ Mphasis 77

⚫ NTT DATA 80

⚫ Optum 83

⚫ TCS 86

⚫ Tech Mahindra 89

⚫ UST Global 91

⚫ Virtusa 93

⚫ Wipro 95

Appendix 98

⚫ Glossary of terms 99

⚫ Research calendar 100

⚫ References 101

Topic Page no.


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Contents

⚫ Introduction and overview

⚫ Summary of key messages

⚫ Payer digital services – market overview

⚫ PEAK Matrix™ for payer digital services

⚫ Vendor profiles

⚫ Appendix


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Our research methodology is based on four pillars of strength

to produce actionable and insightful research for the industry

⚫ Market thought leadership

⚫ Actionable and insightful research

⚫ Syndicated and custom research deliverables

Robust definitions

and frameworks

(PEAK Matrix™, market

maturity, and technology

adoption/investment)

1Primary sources

of information

(Annual contractual &

operational RFIs, service

provider briefings & buyer

interviews, and web-based

surveys)

2Diverse set of

market touchpoints

(Ongoing interactions across

key stakeholders, input from

a mix of perspectives and

interests, supports both data

analysis and thought

leadership)

3Fact-based research

(Data-driven analysis

with expert perspectives,

trend analysis across market

adoption, contracting, and

service providers)

4

Services

Industry

Service

Enablers

Service

ProvidersEnterprises

Proprietary & Confidential. © 2011, Everest Global, Inc. 8

Total Value Equation

Impact on value

proposition to market

Impact on efficiency or

effectiveness of process

Impact on cost of process

Low High

High

Low

Strategic focus

Pro

cess e

xp

ert

ise

Domain expertise

1x

0.1x

10x

⚫ Proprietary contractual database of healthcare IT Services (ITS) contracts (updated annually)

⚫ Round-the-year tracking of all major healthcare IT service providers

⚫ Dedicated team for healthcare outsourcing research, spread over two continents

⚫ Over 20 years of experience in advising clients on ITS-BPS-related decisions

⚫ Executive-level relationships with buyers, service providers, technology providers, and industry associations


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Everest Group’s definition of digital services

Source: Everest Group (2019)

Cloud

infrastructure

Cognitive / Artificial

Intelligence (AI)

Analytics Sensors 3-D

printing

Big data Internet-of-

Things (IoT)

Digital

cybersecurity

Software-as-a-

Service

Enabling layer

Interaction layer

Integration challenge

Standards Systems integration Agile/DevOps Automation

Next-generation

UI/UXSocialMulti-channel Chat Touch

screens

Visualization Virtual Reality

(VR)Mobility Voice

recognition

Digital is a set of underlying technologies that dramatically enhance the experience of users – customers, employees, and partners.


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Background and scope of the research

Enterprises have made digital adoption the bedrock of their growth strategy in recent years, to optimize processes, reduce costs, and deliver better

customer experience, all in the pursuit of higher revenue growth. The healthcare payer industry is no exception. Digital technologies can make internal

workflows more efficient, bring care outside hospitals, offer network management transparency & efficiency, and help reduce frauds.

To support enterprises on their digital journeys, service providers are ramping up capabilities through healthcare-specific partnerships and acquisitions.

This, in turn, is driving the need for research and market intelligence on demand and supply trends in healthcare payer digital services. Everest Group’s

healthcare ITS research program addresses this market need by analyzing outsourcing trends and service provider capabilities in healthcare payer digital

services.

In this report, we analyze the capabilities of 23 IT service providers specific to the healthcare payer sector globally.

These service providers are mapped on the Everest Group PEAK Matrix™, which is a composite index of a range

of distinct metrics related to a provider’s capability and market impact. We focus on:

⚫ Digital services market trends for healthcare payers

⚫ The landscape of service providers for healthcare payer digital services

⚫ Assessment of the service providers on several capability- and market success-related dimensions

Scope of this report:

Industry

Healthcare payer

Geography

Global

Services

Digital services


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This report is based on four key sources of proprietary information

⚫ Proprietary database of IT services contracts of major IT service providers

with healthcare digital services in scope of work (updated annually)

⚫ The database tracks the following elements of each contract:

– Buyer details including size and signing region

– Contract details including service provider, contract type, TCV & ACV,

service provider FTEs, start & end dates, duration, and delivery locations

– Scope details including share of individual buyer locations being served

in each contract, Line of Business (LOB) served, and pricing model employed

⚫ Buyer reference interviews, ongoing buyer surveys, and interactions

⚫ Drivers and challenges for adopting healthcare digital services

⚫ Assessment of service provider performance

⚫ Emerging priorities

⚫ Lessons learnt and best practices

⚫ Proprietary database of IT service providers (updated annually)

⚫ The database tracks the following for each service provider:

– Revenue and number of FTEs

– Number of clients

– FTE split by different LOBs

– Revenue split by region

– Location and size of delivery centers

– Technology solutions developed

Service provider briefings

⚫ Vision and strategy

⚫ Annual performance and future outlook

⚫ Key strengths and improvement areas

⚫ Emerging areas of investment

Service providers assessed

Note: Assessments for Accenture, CGI, Citius Tech, Conduent, EPAM, HTC Global Services, and IBM exclude service provider inputs and are based on Everest Group’s

proprietary Transaction Intelligence (TI) database, service provider public disclosures, and Everest Group’s interactions with healthcare firms that are buyers of digital services

The source of all content is Everest Group unless otherwise specified

Confidentiality: Everest Group takes its confidentiality pledge very seriously. Any contract-specific information collected will only be presented back to the industry in an aggregated fashion


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Contents





⚫ Vendor profiles

⚫ Appendix


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Notes from the trenches – how healthcare payers are adopting digital

Factors such as shift from a volume- to value-based

care model, growing importance of customer-

centricity, entry of BigTech players, and increase in

analytics and AI usage explain the urgency shown

by healthcare payers in adopting digital

The overall healthcare payer

digital services market is close

to a US$9 billion opportunity.

This market has seen the

maximum growth in North

America

Payers are focusing on key areas –

product discovery (enrollment and risk

profiling), medical intervention, and

coordinated care (claims management

and member follow-ups) – with digital

initiatives to create differentiated impact

Key challenges in payer digitalization include siloed

operations, financial struggles, disconnected information

systems, regulatory uncertainty, fragmented member

information, and legacy IT; investments in data

interoperability, change management, process

reengineering, and platform modernization can

overcome these challenges


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⚫ The overall healthcare payer digital services market is close to

US$9 billion opportunity

– This is expected to grow at a rate of ~13% over 2018-2025

⚫ Analysis of the service provider landscape for healthcare

payer digital services through our PEAK Matrix assessment

highlights the following categories:

– Leaders: Accenture, Cognizant, Infosys, NTT Data, TCS,

Optum and Wipro

– Major Contenders: Atos, Capgemini, Citius Tech,

Conduent, DXC Technology, emids, HCL Technologies,

Hexaware, IBM, Mphasis, UST Global, and Virtusa

– Aspirants: CGI, EPAM, HTC Global Services, Tech

Mahindra

⚫ Leaders have established themselves as front runners to

support large customers. They differentiate themselves

through balanced portfolios, the ability to come up with

innovative digital use cases, and continued investments in

technology and services capability development

⚫ For major contenders, their healthcare payer digital portfolios

are not as balanced and comprehensive as those of the

Leaders (either in terms of coverage across the payer value

chain or LOBs) to cater to the differentiated needs of the

payers. This is reflected in either their low vision and capability

positioning or low market impact

⚫ Aspirants lack meaningful digital capabilities for healthcare

payers, largely exhibiting an opportunistic focus. Some of

these players are developing the practice around strategic use

cases to create traction

Notes from the trenches – service provider landscape

R

Vision & capability

(Measures ability to deliver services successfully)

Ma

rke

t im

pa

ct

(Me

asu

res im

pa

ct cre

ate

d in

th

e m

ark

et)

Note 1: PEAK Matrix specific to healthcare payer digital services

Note 2: Assessments for Accenture, CGI, Citius Tech, Conduent, EPAM, HTC Global Services, and

IBM excludes service provider inputs and are based on Everest Group’s proprietary

Transaction Intelligence (TI) database, service provider public disclosures, and Everest

Group’s interactions with buyers

Leaders Major Contenders Aspirants Star Performers

Everest Group Healthcare Payer Digital Services PEAK Matrix™

Assessment 2020

LeadersMajor Contenders

Aspirants

NTT DATAOptum

CognizantAccentureWipro

Infosys

DXC Technology

HCL TechnologiesTCS

IBMemids

HTC Global Services

CGI

EPAMTech Mahindra

Hexaware

Virtusa

UST Global Capgemini

Atos

ConduentMphasis

CitiusTech


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Contents





⚫ Vendor profiles

⚫ Appendix


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Defining and separating the truly digital from the non-digital


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As enterprises transcend the digital maturity curve, their average

digital spend as a percentage of the total business spend is

expected to increase

40-50%

Sample size: Based on feedback collected from 45 buyers and 21 (digital) service providers in 2018


⚫ With enterprises making an effort to

determine the future state of processes to

make it more customer-centric, the spend

toward modernizing the core IT functionality

is increasing

⚫ Another reason is the blurring of boundaries

between what is considered as digital and

non-digital spend

20-30%

⚫ We anticipate that the increase will come

from cloud and infrastructure services,

digital integration, and data management

⚫ The verticals with the majority of increase

will be BFSI, healthcare, and manufacturing

Digital spend as a percentage

of the overall business spend

Percentage increase in the digital spend

anticipated over the next 12-24 months


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A number of factors dictate that healthcare firms embark on the road

to digital transformation

Changing regulatory

environment

Value-based care

Abundance of patient data

Changing role of payers

Rising healthcare costs

Need for internal efficiency

Drivers of digital

adoption for healthcare payers

Data sources

Digital

++++++

Technology tenets

Mobility

Social

Cloud

Analytics

Member experience

Internet of Things

Cognitive intelligence

Automation


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Market trends

Shift to value-based care and changing market landscape due to the entry of BigTech

players are some of the key trends

Growing importance of customer-centricity and a better customer experience

Growing prevalence of preventive care models as a response to value-based care

Payers are focusing on wellness and preventive care models to

increase awareness of health among members. IoT devices including

wearables are used to monitor patient health at all times

There is an increasing demand amongst customers for a better end-user

experience. Digital tools are being used by payers for a better customer

engagement and to lower administrative and healthcare costs

Entry of BigTech players

There is a threat of disruption due to BigTech players entering the

healthcare industry such as Amazon, Apple, Facebook, and Google,

with announcements of significant investments. These players are

leveraging their core business strengths and expertise in analytical and

other digital capabilities to build healthcare-specific solutions

Increase in analytics and AI usage

Analytics has the potential to derive actionable insights from vast amounts

of structured as well as unstructured data. AI is now being used for

numerous applications in healthcare such as reducing frauds, predictive

diagnosis, voice assistants, and improving process efficiency


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Healthcare payer digital services market has seen the most growth

in areas of claims management due to increasing number of

fraudulent cases

100% = US$8.9 billion

⚫ Payers are increasingly leveraging advanced and emerging digital technologies to address customer, operational, and business-model

challenges

⚫ Greater cloud adoption arising from greater electronic health records implementation, high focus on data security to protect patient data

and greater adoption of analytics in claims management is driving the growth of digital in healthcare

⚫ Claims management has seen the maximum adoption of digital. Payers are using next-generation tools in claims management to solve

the issues of increasing number of fraudulent claims and reduce the administrative burden of manually updating them

Payer digital market; revenue split by value chain element

Percentage of total (2018)

13.8%

21.7%

17.4%

22.3%

24.8%

Network management

Claims

management

Care management

Policy servicing

and management

Product development


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Healthcare payer digital services market

Rising need to improve the core competencies in order to reduce costs and human

intervention, is driving widespread adoption of automation in healthcare1

Payer digital services global market

US$ billion

IT services implications and opportunity areas

⚫ Automation and data & analytics are the biggest opportunity areas within digital services

– Cost takeout mandate, rationalization of IT platforms, and intrinsic talent issues are expected to drive the push for widespread

automation adoption

– High potential use-cases for data and analytics going forward include claims, population health, and fraud detection

– While AI has potential use cases and is being piloted, standardizing data issues will be a precursor to scaled adoption

⚫ Security services pose a pressing need as the healthcare industry has remained at high risk for cyber-attack, resulting in a significant

number of stolen health records over the past years

1 These technology themes are not mutually exclusive


CAGR

Business trends

⚫ The overall healthcare payer digital services market

is close to a US$9 billion opportunity

⚫ Payers are leveraging digital technologies to

transform operations. Increased cost efficiency,

enhanced member experience/engagement, and

improved time to market launch are the key drivers

for adopting digital for payers

⚫ Lack of proven ROI, high cost of deployment, and

lack of scalability and technology maturity are the

key digital transformation challenges for payers

2.6

8.14.4

14.1

0.6

1.6

2.2

7.1

1.1

3.2

2018 2025

Data and Analytics

Automation

IoT

Security

AI/ML/Cognitive

21.1

8.9


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Enterprises are involving service providers in their key strategy

decisions and expect them to be domain experts

Service providers’ performance rating on the dimension in 2019

Strategic

partner

5.5

Talent

management

Domain

expertise

Commercials

Technical

expertise

Client

management

2 1064 8

Service providers’ performance rating on the dimension in 2018

7.5

7.8

8.4

9

7

8

8.2

8.8


6.5

Healthcare enterprise perception of service provider capabilities

2019; Ratings on a scale of one to ten

Service providers are handling attrition better than before and are trying to

keep the delay in refilling positions minimal

Enterprises are involving service providers at the decision-making table in

order to bring value. Service providers, however, still need to showcase a

higher order thinking capability to convince enterprises

Enterprises expect service providers to help them navigate through

rapidly evolving industry-specific complexities and regulatory

uncertainties. Previous expertise ratings have not changed

Enterprises are particularly satisfied with the pricing competitiveness and

flexibility offered by service providers. Some players are already offering

innovative commercial constructs and taking on a part of the risk in

contract agreements

Enterprises perceive service providers to be technically competent.

Technical expertise has become a hygiene factor for landing digital deals

Service providers continue to manage clients well. The expectation from

enterprises is now toward agility and responsiveness, with effective

project management now being a hygiene factor


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Demand-side pain points Technology interventions

The payer industry has a high scope for digital adoption to address

the pain points of the market and move toward a customer-centric

model with a focus on value-based care

Analytics used for insights and model development

for a patient-centric plans, with AI automation

solutions reducing processing times for payersProduct development

Improve data sharing between payer and providers.

Reduce claims spend and improve provider data

accuracy

Blockchain solutions providing an immutable source

of records and a secure distributed ledger model help

maintain payer-provider record quality and data

accuracy

Onus of sharing the care of patients is not just

on providers but is jointly shared between

payers and providers. Payers require relevant

individual patient data for services such as

remote patient monitoring and patient education

Data analytics being used to develop meaningful

insights and reduce time for analyzing huge

amount of patient data. Telehealth and digital

devices allow remote access to healthcare and

real-time tracking of patient data

Policy servicing

Network management

Care management

Claims management

Need to reduce steps and increase accuracy while

tackling fraudulent, inaccurate claims. Reduce

reworking events and processing time, thereby

reducing the administration overheads

Use of AI-based predictive analytics to increase

accuracy and reduce manual error while screening

claims at each stage of the claims-process for

detection of fraudulent, dirty, and waste claims

Customer-centric plans need to be developed as the

industry is witnessing a shift from being more payer-

and provider-centric to being more customer-centric

Customer expectations are rising for digital channels

and digital experience with improvement in ease of

access for better customer journey and engagement

Mobile applications leveraged for access to tools and

information delivery, with the application of chatbots

to enhance engagement at multiple touchpoints


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Payers are moving toward adoption of analytics and automation in

order to speed up development of customer- centric plans

Healthcare payers using AI-analytics for insight generation and decision-making

Anthem leverages big data analytics for insights into the behaviors, risks, and such actions of its members.

It also announced collaboration with Stanford researchers to leverage AI for price transparency

Use of Analytics/AI/RPA in product development

⚫ Analytics solutions for data from care and claims management

systems to assist product development through extracting

actionable insights and building customer-centric plans

⚫ AI-enabled analytic solutions to efficiently model cost, risk,

carry out patient stratification, and even suggest the best plans

for customers

⚫ Robots enable automation of manual receipt checking, data

loading, and plan renewals

TCS offers an analytics based health plan framework that helps its users by recommending the best health

plan during sales based on data such as claims history, and coverage details.

Current challenges in product development

⚫ Required to successfully identify high-risk, high-cost, and high-

priority patients

⚫ Need for efficient patient risk stratification, identification of

upcoming high-cost medical events, and modeling of risk

⚫ Bring tailored plans for individuals and employers, while

reducing development time and cost


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Bringing better experience to customers and improving customer

journey is a priority for payers

Arkansas Blue Cross and Blue Shield app allows members to pay their bill, look up in-network doctors, search

for hospitals and dentists, find locations and stores for face-to-face help, view recent claims securely, and

review coverage information and dependents.

Cigna’s WhatsApp service chatbot, co-developed with Clare.AI, allows customers to access information and

services, as finding a doctor – and their details such as opening hours and making a booking – and will include

the ability to make insurance claims later

Using AI chatbots / voice assistants and app-based solutions

⚫ Developing mobile apps with integrated services for one-stop

solution, ease of access, and inclusion of guided user tools to

aid decision-making and improve customer journey

⚫ Chatbots and voice assistants improve customer engagements

and deliver continuous care. Voice assistants with AI increase

meaningful conversations and are great for customer

engagements.

⚫ AI, NLP, and RPA can be used for automating the processes

related to policy administration

Current challenges in policy servicing

⚫ Improving information transparency and developing customized

offerings as per specific customer requirements. Shift from one-

to-many to one-to-one model

⚫ The need to improve customer engagement and simplify

customer journey requires better offerings in the form of digital

tools and channels

⚫ Several processes in policy administration such as member

enrollment, fulfillment, eligibility, billing, and customer services

are labor-intensive and are thus prone to errors

Healthcare payers leveraging mobility and AI chatbots

UnitedHealthcare’s app for its members provides access to tools that allow them to track their benefits and

compare pricing and access on-demand telemedicine, and aims to provide a one-stop-shop for healthcare


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Optimizing data sharing across network and keeping transactional

costs in check is a key area of focus for payers

NASCO partnered with Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield

of Michigan (BCBSM), Horizon Healthcare Services, Inc., and Express Scripts to form a consortium named

Coalesce Health AllianceSM (Coalesce), focused on evaluating the application of blockchain to improve the

efficiency and accuracy of healthcare data exchanges across entities within the Blues' ecosystem

Blockchain promoting better data management and sharing

⚫ Blockchain for single source of truth solution to maintain data

quality across the entire network, increase ease of access, and

reduce the cost of transaction

⚫ Providing real-time updates to healthcare providers and self-

help tools to employers for reducing downstream costs and

better understanding of employee health plan requirements

Current challenges in payer-provider network management

⚫ Managing and leveraging large provider network data,

maintaining data quality, and providing seamless sharing of

data across network points

⚫ Reducing transactional costs and time involved in data loading,

data analyzing, and pending claims

Healthcare payers and service providers are improving data handling with blockchain

Wipro provides network management solutions such as provider onboarding, provider credentials management,

cognitive data validation, Medicare encounter, and reimbursement/reconciliation suite of products. Wipro’s

solutions are designed to manage various providers, payers, and beneficiary (patients) data in compliance with

government regulations. Wipro Provider Life Cycle Management (PLM) in partnership with Reltio, Medversant

and Change healthcare provides end to-end provider life cycle management


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Care management is not limited to the walls of the hospital, with the

development of wellness options and preventive healthcare

Healthcare payers leveraging Telehealth and on-demand services

Teladoc by Aetna helps its members get in touch with licensed doctors round the clock via video, call, or mobile

app, especially for treatment of non-emergency conditions such as allergies and general consultation. This has

allowed its members to skip long wait times and avoid hefty charges billed at the ER for non-emergency cases

Capital BlueCross launched a new virtual care app aimed at behavioral health services. Members can visit a

physician at any time, via their smart phone or computer

Anthem's AIM Specialty Health subsidiary provides physicians with actionable data insights to take decisions in

high risk areas such as oncology. Anthem has developed an analytics platform in support of Vivity that provides

health systems with population health data and advanced analytics solutions

Use of IoT and telehealth for remote healthcare

⚫ Use of IoT in med-devices to allow real-time monitoring and

access to live patient data including day-to-day activities of

users. Analyzing this data to provide personalized health-

related expert advice

⚫ Develop digital engagement plans using mobile, and other

online mediums. Mobile applications allow mobile phone users

to remotely access wellness and preventive care programs

⚫ On-demand 24/7 access to in-network doctors through mobile

access

Current challenges in care management

⚫ Recent shift toward value-based care models incentivizes

payers for developing preventive healthcare and wellness

options for patients

⚫ Traditional methods of care delivery and engagement with

patients are becoming less effective as patients now require

cost- and time-efficient healthcare options

⚫ Large amount of healthcare data is available, which can be

analyzed for predicting health outcomes and saving millions


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Healthcare payers are extensively leveraging automation and AI/ML

for claims processing in order to reduce manual work, reduce time,

and identify frauds and errors

Aetna has developed an AI application to settle claims and analyze complex healthcare provider contract

formation. This means that there is less manual intervention, resulting in fewer errors and also the valuable

workforce can address more complex tasks

Cotiviti’s signature Fraud Waste and Abuse (FWA) solution is an automated overpayment detection and

protection system that aims to help payers identify potential fraud cases, spot billing misunderstandings and

mistakes, and adhere to medical policies

Healthcare payers and service providers employing AI/ML and analytics

CMS has replaced its pay-and-chase approach to reducing Medicare fraud, waste, and abuse with pre-payment

model of claims detection. AI/ML will be used to develop quicker anomaly detection for identifying fraud,

particularly before the claim is paid

Current challenges in claims processing

⚫ Manual processing of the large amount of claims received, is

highly time-consuming and errors requiring manual rework lead

to an increase in pending cases that add to the already rising

costs and shrinking margins

⚫ High number of fraudulent, waste, and dirty claims require

multiple steps back and forth and end in tardy turnaround times

⚫ Growing prevalence of value-based models, rising friction

between payers and providers due to pay and chase approach,

and increasing complexity of claims require technological

intervention

Application of AI/Automation in claims improvement

⚫ Automation of processes such as claims adjudication, claims

editing, and overpayment recovery removes manual labor

requirements, thereby reducing times extensively

⚫ AI scrutinizes claims effectively and increases accuracy of

detection and prevention of fraudulent claims. In the event of a

fraudulent or denied claim, reprocessing is expedited using

automation

⚫ Analytics can be used to detect fraudulent claims before they

are paid, reducing the friction that arises from a traditional pay

and chase approach and helping to reduce the administrative

overheads arising from rework


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Contents





⚫ Vendor profiles

⚫ Appendix


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®

™

®

Everest Group PEAK Matrix™ is a proprietary framework for

assessment of market impact and vision & capability

Everest Group PEAK Matrix

Vision & capability

Measures ability to deliver services successfully

High

Low

Low High

Leaders

Aspirants

Ma

rke

t im

pa

ct

Measure

s im

pact cre

ate

d in t

he m

ark

et

Major Contenders


EGR-2019-45-R-348529

®

™

®

Services PEAK Matrix™ evaluation dimensions

Measures impact created in the market –

captured through three subdimensions

Market adoption

Number of clients, revenue base,

YOY growth, and deal

value/volume

Portfolio mix

Diversity of client/revenue base

across geographies and type of

engagements

Value delivered

Value delivered to the client

based on customer feedback

and transformational impact

Vision and strategy

Vision for the client and itself;

future roadmap and strategy

Scope of services offered

Depth and breadth of services

portfolio across service

subsegments/processes

Innovation and investments

Innovation and investment in the

enabling areas, e.g., technology

IP, industry/domain knowledge,

innovative commercial

constructs, alliances, and M&A

Delivery footprint

Delivery footprint and global

sourcing mix

Measures ability to deliver services successfully.

This is captured through four subdimensions

Mark

et

imp

act

Vision & capability

Major Contenders

Leaders

Aspirants


EGR-2019-45-R-348530

®

™

®

Everest Group confers the Star Performers title on providers

that demonstrate the most improvement over time on the

PEAK Matrix™

Methodology

Everest Group selects Star Performers based on the relative YOY improvement on the PEAK Matrix

Year 1

Year 0

Ma

rke

t Im

pa

ct

Vision & capability

We identify the service providers whose improvement

ranks in the top quartile and award the Star Performer

rating to those service providers with:

⚫ The maximum number of top-quartile performance

improvements across all of the above parameters

AND

⚫ At least one area of top-quartile improvement in

performance in both market success and capability

advancement

The Star Performers title relates to YOY performance for a given vendor and does not reflect the overall market leadership position, which is identified as

Leader, Major Contender, or Aspirant.

In order to assess advances on market impact,

we evaluate each service provider’s performance

across a number of parameters including:

⚫ Yearly ACV/YOY revenue growth

⚫ # of new contract signings and extensions

⚫ Value of new contract signings

⚫ Improvement in portfolio mix

⚫ Improvement in value delivered

In order to assess advances on vision and

capability, we evaluate each service provider’s

performance across a number of parameters

including:

⚫ Innovation

⚫ Increase in scope of services offered

⚫ Expansion of delivery footprint

⚫ Technology-/domain-specific investments


EGR-2019-45-R-348531

®

™

®

Everest Group PEAK Matrix™

Healthcare Payer Digital Services PEAK Matrix™ Assessment 2020

Note 1: PEAK Matrix specific to healthcare payer digital services

Note 2: Assessments for Accenture, CGI, Citius Tech, Conduent, EPAM, HTC Global Services, and IBM excludes service provider inputs and are based on Everest Group’s proprietary

Transaction Intelligence (TI) database, service provider public disclosures, and Everest Group’s interactions with buyers

Vision & capability

(Measures ability to deliver services successfully)

Mark

et

imp

act

(Measure

s im

pact cre

ate

d in t

he m

ark

et)

Everest Group Healthcare Payer Digital Services PEAK Matrix™ Assessment 2020

Leaders

Major Contenders

Aspirants

Star performers

High

Low

Low High

LeadersMajor Contenders

Aspirants

NTT DATAOptum

Cognizant

AccentureWipro

Infosys

DXC Technology

HCL TechnologiesTCS

IBMemids

HTC Global Services

CGI

EPAMTech Mahindra

Hexaware

Virtusa

UST Global Capgemini

Atos

ConduentMphasis

CitiusTech


EGR-2019-45-R-348532

®

Leaders:

Accenture, Cognizant, Infosys, NTT Data, TCS, Optum and Wipro

Leaders have established themselves as front runners to support large healthcare payer customers that prefer service providers to help them achieve

transformation through digital initiatives

⚫ These players have balanced portfolios, are able to come up with innovative digital use-cases for healthcare firms, and continue to keep pace with the

market dynamics through continued investments in technology and services capability development (internal IP/tools, M&A, partnerships, etc.)

⚫ Leaders have showcased high levels of proactiveness in taking their innovations and next-generation service offerings to clients

⚫ They tend to be the providers of choice for large healthcare firms looking for partners with a similar global footprint

⚫ That said, the current Leaders face a stiff challenge from progressive Major Contenders in terms of both digital services capabilities and commercials.

Hence, they need to focus on building effective solutions that leverage next-generation technology trends and also address the cost-takeout mandate

Major Contenders:

Atos, Capgemini, Citius Tech, Conduent, DXC Technology, emids, HCL Technologies, Hexaware, IBM, Mphasis, UST Global, and Virtusa

The Major Contenders segment comprises a varied mix of global MNCs, large- & mid-sized firms, and healthcare specialists

⚫ While some have built meaningful capabilities to deliver a wide range of digital services across the healthcare LoBs and value chain, others focus on

differentiating by specializing in specific areas within the healthcare domain

⚫ The service portfolios of Major Contenders are not as balanced as compared to Leaders, and also tend to be less comprehensive in value chain

coverage

⚫ However, these players are offering the Leaders stiff competition by making high-profile investments and meaningful partnerships around digital offerings.

⚫ For such players, an opportunity lies in engaging small and medium-sized buyers, especially since this market segment has not been addressed

meaningfully by Leaders

Aspirants:

CGI, EPAM, HTC Global Services, Tech Mahindra

Aspirants are majorly focused on mid-sized clients with low focus on large and very large clients

⚫ Aspirants lack meaningful digital capabilities for healthcare payers, exhibiting largely an opportunistic focus. Some of these players are developing the

practice around strategic use cases to create traction

⚫ Some of the players are trying to grow their healthcare businesses through industry-specific offerings

Healthcare payer digital services PEAK Matrix™ characteristics



EGR-2019-45-R-348533

®

™

®

Everest Group has identified three vendors as the

“2020 Star Performers”

Payer digital

star performers

Distinguishing features

of 2019 vision and capability

Distinguishing features of 2019

market impact

Change in positioning on

PEAK Matrix

Entered the

Leaders category

Entered the

Leaders category

⚫ Multiple partnerships with players

such as partnership with Google

cloud to leverage their cognitive, IoT

and other digital solutions

⚫ Increased focus on platforms and

solutions to solve business-specific

problems

⚫ Multiple partnerships and alliances,

both vertical and horizontal specific,

to strengthen their digital

technologies

⚫ Multiple investments to upskill talent

in digital services

⚫ Expanded their network of

healthcare engagements with

large national plans and Blues

⚫ Delivered value by innovative

deal constructs

⚫ Multiple client wins in the payer

market

⚫ Distinguished for delivering value


EGR-2019-45-R-348534

®

Service provider

Market impact Vision & capability

Market

adoption Portfolio mix

Value

delivered Overall

Vision and

strategy

Scope of

services

offered

Innovation

and

investments

Delivery

footprint Overall

Accenture

Cognizant

NTT Data

Optum

Wipro

Measure of capability: High Low

Summary dashboard | Market impact and vision & capability

assessment of providers for payer digital services

Leaders


EGR-2019-45-R-348535

®

Service provider


Market


Value

delivered Overall

Vision and

strategy

Scope of

services

offered

Innovation

and

investments

Delivery

footprint Overall

Atos

Capgemini

CitiusTech

Conduent

DXC Technology

emids

HCL

Technologies

Hexaware




Major contenders (page 1 of 2)


EGR-2019-45-R-348536

®

Service provider


Market


Value

delivered Overall

Vision and

strategy

Scope of

services

offered

Innovation

and

investments

Delivery

footprint Overall

IBM

Mphasis

UST Global

Virtusa




Major contenders (page 2 of 2)


EGR-2019-45-R-348537

®

Service provider


Market


Value

delivered Overall

Vision and

strategy

Scope of

services

offered

Innovation

and

investments

Delivery

footprint Overall

CGI

EPAM

HTC Global

Services

Tech Mahindra




Aspirants


EGR-2019-45-R-348538

®

Service provider


Market


Value

delivered Overall

Vision and

strategy

Scope of

services

offered

Innovation

and

investments

Delivery

footprint Overall

Infosys

TCS




Star Performers


EGR-2019-45-R-348539

®

Contents





⚫ Vendor profiles

⚫ Appendix


EGR-2019-45-R-348540

®

Accenture | Payer digital services profile (page 1 of 2)

Overview

Scope of digital services for payer digital

Cloud, big data and analytics, social media, cybersecurity, mobility, IoT, and

blockchain

Adoption by buyer groups

Small (annual revenue < US$1 billion)

Medium (annual revenue = US$1-5 billion)

Large (annual revenue > US$5 billion)

Payer digital services focus

by subvertical

Public health plans Private health plans

Healthcare payer digital services delivery map

Healthcare payer digital services revenue

US$100-US$150

million

Adoption by LOBs

Product development Policy servicing and management

Claims management

Network management Care management

High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Canada

Philippines

Latvia

<US$50

million

>US$150

million

Strengths

⚫ Focus on differentiation through a consultative-led approach

⚫ Strong vision for the future of digital with a focus on DARQ technologies, which

include Distributed Ledger Technology (DLT), AI, Extended Reality (XR), and

quantum computing

Areas of improvement

⚫ Increase focus on small and mid-sized payers

⚫ Innovative pricing model such as outcome-based pricing and innovative

commercial constructs

>1,000 FTEs 500-1,000 FTEs 100-500 FTEs <100 FTEs


EGR-2019-45-R-348541

®

Accenture | Payer digital services profile (page 2 of 2)

Overview

Proprietary solutions (representative list)

Solution Details

Accenture Public Health

Platform (APHP)

It is for end-to-end services with core platform technology and Business Processing Services (BPS) for government clients. APHP is the

foundation for its offerings in the HIX and Medicaid market. The platform helps states and managed care organizations to reduce cost and

the risk of deploying new capabilities, and provides budgeted focus on improving outcomes

Accenture public service

platform

It is a flexible and service-based technology platform to help public health agencies manage a wide array of citizen services in an integrated

manner and improve service delivery

Predictive health

intelligence

It is a suite of analytics-based solutions that helps enterprises to build evidence-driven models. Predictive Health Intelligence uses data and

analytics to determine the treatments and services that lead to better patient provider and economic outcomes. Accenture has formed

alliances with Explorys, Liaison Technologies, and Predixion to deliver these solutions

State Medicaid MMIS It provides various services and offerings to improve health outcomes in targeted regions in the United States

Intelligent patient platform It helps to develop and deliver comprehensive patient programs based on the requirements of unique patient segments

Health experience platform It is a cloud-based solution that enables health insurers to deliver seamless customer experiences

Ella It is a virtual care assistant for patients that provides a suite of services including medication reminders, vitals tracking, and appointment

scheduling as a part of patient engagement support

Ethan It is a virtual service assistant for healthcare providers that enables companies to help providers engage with patients, monitor their health

activity, and coordinate with other care team members to provide critical services in a more holistic manner

Recent activities (representative list)

Development Type Details

Oracle

Partnership

Partnered with Oracle to develop solutions that enable insurers to digitize their financial data and help them in financial

reporting of their insurance contracts

Multiple partnerships Partnered with Salesforce.com, AWS, SAP hybris, Adobe, GE, Alteryx, Apigee, Cloudera, Hortonworks, HP, IBM,

Informatica, Intel, Microsoft, Oracle, Pega, Qlik, Apple, Samsung, and others


EGR-2019-45-R-348542

®

Atos | Payer digital services profile (page 1 of 3)

Overview


Cloud, big data and analytics, social media, cybersecurity, and IoT






by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

Strengths

⚫ Strategic alliances such as with google cloud, and Siemens to strengthen its

digital portfolio across analytics, IoT, and cloud services

⚫ Building strong digital transformation capabilities with data analytics, cloud

computing, digital workplace services, and cognitive healthcare platforms


⚫ Increase focus on mining and expanding into existing accounts

⚫ Demonstrating strong proof points for digital consulting capabilities



EGR-2019-45-R-348543

®


Offerings and recent developments

Proprietary solutions for healthcare payer digital services (representative list)

Solution Details

Configuration automation

solution for members

It Improves consumer experience through automated creation of FSA/HRA funding accounts for new and renewal groups in core systems or

COTS products. This improves time to market and reduces the review workflows. Improved accounting process with high accuracy to

process refunds in core systems or COTS such as Facets through RPA using Syntbots. All manual receipts such as checks from providers

and members are posted to core processing systems through automated robots

Clinical documentation

improvement solution

It increases savings and improves reimbursements through AI/ML/NLP processing for better clinical documentation on EHR. This in turn

improves coding accuracy and reduces administrative overheads

Enrollment First Pass Rate

Improvement and Accuracy

solution

It improves enrollment first pass rate through industry leading solutions on Salesforce/velocity platform. This enables faster time to market

and facilitates groups and member enrollments by segregating the core systems of record from this process.

Increased member outreach through mobile-enabled CRM application that helps agents track leads and close enrollments faster

Drive Actionable Insights –

Provider Contracts

It enables better negotiations and contracting to cover exhaustive services through What-if modeling, accurate pricing, and forecasting

capabilities with insights from claims and contracts data. This solution addresses both professional and facility contracts.

Improved accuracy of contracting for facility and professional contracts through RPA migration to COTS/in-house from legacy platforms

Preventive Care solution It enables real-time processing of care management application on the cloud that integrates data from various sources and personal

devices. This enables decision accuracy and health outcomes by care managers through data analytics.

Drive holistic health program by enabling preventive care and wellness through device integration and predictive modeling on treatments

Connected Health solution It includes TeleHealth, mHealth, wearables, and digital devices solution, driving care from anyplace

Claims Pricing as a service It is a service model for legacy systems through UI modernization, rules-based pricing engine that can support legacy, COTS, and any in-

house claims processing systems. It also includes Microservices development and API management to integrate with multiple claims pricing

systems

Safe Passage

transformation

It improves time to market and digital transformation solution from legacy to COTS products such as Healthedge and Facets

ITOps for Legacy and

COTS

It reduces cost and improves agility and efficiency of run-the-business operations across diverse technology platforms powered by intelligent

automation

Adoption Solution –

Handling Change

Management

It ensures organizations gain value from digital transformation and technology adoption through engaged leadership, speed to proficiency,

performance metrics, and adoption sustainment


EGR-2019-45-R-348544

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Key events (representative list)

Event name Type of event Details

Google Cloud

Alliance

In 2018, formed an alliance and now three operating Atos/Google AI labs exist that drive customer co-innovation

SIEMENS In 2018, formed an alliance, now have more than 200 joint customers across all verticals

Vlocity In 2018, formed an alliance to focus on joint GTM and solution creationAWS In 2018, became the strategic GSI Partner with more than 550 certified experts with 750+ Certs

Microsoft Involved in an alliance with MicrosoftGold Partner, which has 7,800+ experts certified on Microsoft technologies

Digital labsInvestment

Invested in 24x7 Digital Labs set up at the development centers with modern infrastructure, where employees can

learn and experiment on any digital technology as well as collaborate with others within and outside the organization


EGR-2019-45-R-348545

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Capgemini | Payer digital services profile (page 1 of 3)

Overview


Cloud, big data and analytics, social media, cybersecurity, UX, VR/AR and IoT






by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

UK, Ireland

Australia

APAC

Europe

Strengths

⚫ Product and solution mix spans evenly across the entire value chain

⚫ Strong focus on self-care and self-access tools, both on member and provider

side

⚫ Acquisition of Altran will improve strategic engagement ability with clients


⚫ Payer vertical-specific acquisitions to reinvent and improve the company's

healthcare domain expertise and current perception in the market

⚫ Demonstrate payer-specific proof points of success with its digital offerings



EGR-2019-45-R-348546

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Overview


Solution Details

Appeals and Grievance

solution

It is a complaint tracking system for insurance payers to track and resolve any complaints that the members or providers may have in areas

related to their health plans

Bookplan It is a scheduling platform that integrates with other administration systems and manages the workflow that supports each patient’s journey

through the treatment process. This helps hospitals to improve patient outcomes, internal efficiency, and capacity

CITRON It is a proprietary care management platform for digitized plan of care claims file and access to provider network

Digicare It is a platform designed to help engage patients in their healthcare journey to observe their treatment and care pathway

Fraud analytics It utilizes a payer’s data to identify and flag potential fraudulent claims. It uses a self-learning algorithm to identify these fraud claims based

on historical data

Group Dental

Administration

It is a framework to build end-to-end solutions for dental insurance offerings within a globally consistent process, which reduces both direct

and indirect costs while enriching service levels for customers

Implementation of member

and provider portal

It helps promote self-service, reduces call center volumes, and increases member and provider satisfaction scores

Member mobile application It is a mobile application designed for millennial’s view that allows users to manage their healthcare policies at any time and on the go

Wellness Active Risk

Management (WARM)

It helps users to capture their day-to-day activities including physical activities, diet, etc. It analyzes the vital health data gathered from users

and presents them with an overall assessment that helps users to monitor their health

Werve It is a wellness offering that promotes and encourages healthy living for its members by rewarding their healthy lifestyle

Medicare Star Rating It is a consulting framework to help payers improve CMS star ratings. It allows insurance companies to identify areas of concern and make

improvements to Medicare Advantage plans

Capgemini’s Straight

Through Processing (STP)

It is an end-to-end offering, which allows the processing of quotes, new business proposals, underwriting, and claims for different insurance

LOBs including life insurance, personal auto, and health

Engagement blueprinting It provides a detailed view that brings together stakeholders from the key functions across the journey, identifies data redundancies and

sources of record, provides a holistic view to diagnose root causes of problems, and establishes non-obvious relationships among people,

processes, and technology, thus increasing visibility across experiential and functional areas


EGR-2019-45-R-348547

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Overview



AltranAcquisition

In 2019, acquired Altran to leverage its capabilities to position as a strategic partner to assist clients in development of

cloud, edge computing, IoT, AI, and 5G technologies

MultipleAcquisition

⚫ In 2018, acquired LiquidHub and Leidos Cyber to strengthen its cybersecurity offerings

⚫ In 2018, acquired AdaptiveLab and Idean to strengthen its digital strategy and design capabilities

Majesco Partnership

In 2018, partnered with Majesco to provide insurance innovation, customer service, and digital capabilities to implement

Majesco’s Life & Annuity (L&A) and Group Core Suite for insurance carriers in the life, annuity, group, worksite, and

voluntary benefits market help them achieve speed to value

PegaPartnership

In 2017, partnered to leverage Appeals and Grievances (A&G) solution to improve SLA compliance and boost quality

with process controls and transparency

Applied Innovation

Exchange (AIX)Investment

In 2018, invested in AIX, a dedicated technology R&D group, and a global platform to enable enterprises to discover

relevant innovations

Digital talent academyInvestment

In 2017, invested in digital talent academy, an initiative to transform the workforce and equip employees with hard and

soft skills

Duck Creek Technologies Partnership In 2017, partnered with Duck Creek Technologies to provide insurance applications and services

Cortex Partnership In 2017, partnered to leverage its RPA tool for claims processing


EGR-2019-45-R-348548

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CGI | Payer digital services profile (page 1 of 2)

Overview








by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

UK

Canada

Philippines

Strengths

⚫ Strong focus on consulting services, along with focus on technologies including

AI and ML

⚫ Meaningful acquisitions to deepen its geographic reach within the US and

outside


⚫ Focus on its breadth of solutions outside care management and claims

management



EGR-2019-45-R-348549

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CGI | Payer digital services profile (page 2 of 2)

Overview


Solution Details

CGI healthcare enterprise

optimization

It is a modelling and analytics solution that enables data-driven insights for managing and forecasting resources, increasing efficiency, and

improving quality and access to care

Medicaid Incentive360 It helps Medicaid and state agencies to comply with eligibility rules and perform payment calculations and application processes

CGI ProperPay It is a suite of solutions and services for reducing claims fraud, waste, and abuse experienced by Medicare, Medicaid, and commercial

payers

CGI CommunityCare 360 It is a set of solutions to improve patient care coordination by bringing together data and systems for home health monitoring and care

planning, worker & ambulance dispatch, and workforce management of mobile home healthcare workers

Health Insurance

Exchange360™ solution

It enables states to effectively implement and manage health insurance exchanges

CGI case management It is a web-based solution that automates and standardizes processes aimed to increase agility, drive productivity, and improve customer

service. It integrates common workflow requirements through a web services integration framework

CGI HotScan It is a suite of solutions and services for complying with combatting terrorist financing and the anti-money laundering regulation

Optimization and

prescriptive analytics

It aligns and optimizes decisions with strategic objectives of the organization, whether financial, clinical, customer experience, or business-

related



Ordo Partnership In 2019, partnered with Ordo to develop a service that prevents fraud for both payers and payees

Affecto Acquisition In 2017, acquired Affecto, a data analytics and business intelligence services firm to enhance the company’s digital

capabilities in analytics and data science

Summa TechnologiesAcquisition

In 2017, acquired Summa Technologies, a growing IT consulting firm in the Pittsburgh region to expand and deepen its

geographic reach throughout the US

MicrosoftPartnership

In 2017, partnered with Microsoft to move the CGI ProperPay solution to Microsoft Azure Cloud in order to leverage

elasticity, speed, and security, and to leverage Microsoft tools such as Cortana to enhance its analytics capabilities

Collaborative ConsultingAcquisition

In 2016, acquired Collaborative Consulting to enhance relationship and footprint in Boston area and the surrounding New

England region


EGR-2019-45-R-348550

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CitiusTech | Payer digital services profile (page 1 of 2)

Overview








by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

UK

Strengths

⚫ Comprehensive solutions and services with a focus on value-based care

⚫ Expertise in data management and advanced analytics solutions with a strong

focus on AI and ML solutions

⚫ Strong healthcare knowledge with strong business growth across payer markets


⚫ Ramp up its marketing efforts to better position its platforms – BI-Clinical, H-

Scale, and SCORE+ – in the healthcare payers market

⚫ Focus on engagements with innovative deal constructs such as gainsharing, as-

a-service, and co-investment with clients



EGR-2019-45-R-348551

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CitiusTech | Payer digital services profile (page 2 of 2)

Overview


Solution Details

Bi-Clinical It is a platform that offers an integrated approach to address the organization’s healthcare reporting and decision support needs. It offers a

range of configurable apps that cover over 750 KPIs for clinical, financial, operational, and regulatory requirements

H-Scale It is a healthcare data integration and management platform that helps organizations build data and accelerate data strategies. With its

modular, configurable, and scalable architecture, it addresses key healthcare information needs including data acquisition, real-time

processing, data security, and advanced analytics

Medictiv It is an end-to-end suite of analytics tools and services to assist health systems, payers, and life sciences companies in leveraging their data

assets to derive actionable insights. It offers capabilities for statistical mining, predictive modelling, ML, deep learning, model life cycle

management, and AI techniques

SCORE+ It enables healthcare organizations to accelerate their value-based initiatives through tailored components for specific industry needs (such

as real-time HEDIS reporting and population health management) and organizations (providers, payers, ACOs, and CINs)



BIC-AuditInvestment

In 2019, launched BIC-Audit, a solution for comprehensive audits of clinical measures. It enables organizations to generate

real-time audit reports across financial, operational, contractual, and regulatory domains that leverage pre-built KPIs’ support

from multiple programs

Medicare Advantage

Performance Suite (MA-

PS)

Investment

In 2019, launched MA-PS, a holistic set of consulting, technology solutions, and services for MA plans to boost the CMS star

ratings and HEDIS scores. It helps MA plans conduct medical management and reimbursement, increase revenue, improve

operations, and achieve compliance

FluidEdge Consulting Investment

In 2018, invested in FluidEdge Consulting to strategically engage with healthcare customers, leverage its technology to define enterprise solutions, and build and deploy them to drive business performance

Opened centersExpansion

In 2017, opened a new technology center in Rochester, the United States, to closely follow on the heels of the two new

centers opened in Mumbai, India, and Dubai, the United Arab Emirates, and strengthen its presence in North America

Tata Memorial Hospital Partnership

In 2017, partnered with Tata Memorial Hospital to extend its support for the use of Percutaneous Intravenous Central

Catheters (PICC lines) for children suffering from cancer


EGR-2019-45-R-348552

®

Cognizant | Payer digital services profile (page 1 of 3)

Overview


Cloud, big data and analytics, social media, cybersecurity, RPA, blockchain and

IoT






by subvertical




US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Canada

Philippines

China

Malaysia

>US$150

million

<US$50

million

Strengths

⚫ Innovative way of looking at the digital impact by focusing on community health

using social determinants, rather than restricting themselves to clinical settings

⚫ Leveraging alliances with BigTech and investments such as uber-health to

create meaningful digital impact


⚫ Enhancing capabilities and domain expertise of their delivery teams

⚫ Driving collaboration/synergies across internal teams and providing a single

clear point of contact for its customers



EGR-2019-45-R-348553

®


Solution name Details

Care Advance Enterprise It is a data-driven care management platform, which streamlines and combines elements of Care Management (CM), disease management

(DM), and utilization management (UM) in a single platform, allowing delivery of targeted health information and wellness campaigns more

effectively, while getting the most out of interactions with members and providers

ClaimSphere QaaS NCQA-certified, end-to-end care quality improvement suite, comprising ClaimSphere HEDIS (for HEDIS measures), StarServ (for Star

ratings), and Clinical+ (for real-time clinical insights on care gaps).

TriZetto StarSERV It is a star rating management and quality improvement solution

TriZetto ClaimSphere

Clinical+

It is a point-of-care platform that facilitates clinical data acquisition and exchange of patient-level detailed analytics

Healthcare Process

Automation (HPA)

It is a healthcare business process automation platform, which allows to engage in “Robots as a Service” (RaaS) models

NetworX It is a contract analysis, claims pricing, and value-based reimbursement administration solution

Onvida It is an omnichannel contact engagement platform that integrates people, processes, and a cloud platform suite, pre-configured for

healthcare and delivered as-a-Service, to engage members/patients across channels and achieve measurable outcomes faster and at a

lower cost

TranZform It is a SaaS-based, multi-channel, modular solution, which facilitates value-based collaboration. It enables digital integration and

engagement across the care continuum

TriZetto Healthcare Cloud

Solution

It is a secure, compliant, and managed services platform for healthcare payers of any size, powered by Microsoft Azure. It provides a

flexible and efficient on-demand infrastructure for increased operational efficiency, automation, and reduced administrative costs. Based on

Cognizant's TriZetto Facets and QNXT end-to-end core administration software, the new solution is available on Azure

TruProvider It is an E2E Provider Data Management platform to accelerate provider credentialing and onboarding

healthCOMPASS It is a predictive analytics-driven solution enabling effective and proactive patient and population care management, which includes:

• Identification of members with the highest probability of hospital readmission or therapy non-adherence; ability to intervene and prevent

utilization

• Enabling optimized clinical resource allocation, focusing on members such asly to respond


Payer Digital Services


EGR-2019-45-R-348554

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TTAP Acquisitions Acquired a platform that accelerates prior authorization and referral processes, cutting the overall TAT from weeks to a

matter of minutes

Zone Acquired Zone that will enhance Cognizant’s capabilities in digital marketing

TMG Health Acquired TMG Health to expand Cognizant's capabilities in Business Process-as-a-Service and embedded analytics

solutions for government and public health programs

Brilliant Service Acquired an intelligent products and solutions company, specializing in digital strategy, product design and engineering,

IoT, and enterprise mobility, with a focus on AI and analytics

NetCentric Acquired a provider of digital marketing solutions specializing in the Adobe Marketing Cloud stack. It will enable

Cognizant to continue its transformation in experience design, realization, and management

Hedera

Consulting

Acquired Hedera Consulting to expand Cognizant's consulting, business insight, and digital transformation capabilities for

clients in Belgium and the Netherlands

SoftVision Acquired SoftVision, a privately held digital engineering and consulting company focused on agile development of

innovative software solutions and platforms

Sisense Partnership & Alliances Formed an alliance as a strategic implementation partner, which Cognizant leverages to deliver business intelligence and

analytics solutions

CognitiveScale Formed a global partnership to deliver augmented analytics solutions based on cloud

Tagetik Formed a global partnership to deliver on-premises corporate performance management software applications

Containerization Formed an alliance as a global and federal system integrator partner for Docker

Microsoft Formed a partnership that focuses on addressing key trends, including mobility, virtualization, globalization, cloud

computing, and social media. Also focused on delivering AI, cognitive, and big data and analytics solutions. Cognizant is

a Microsoft Gold Certified Partner

Google Formed an alliance as a Global Systems Integrator (GSI) for the Google for Work™ service

Adobe The partnership brings Cognizant’s digital marketing services together with Adobe’s acclaimed Marketing Cloud

technology to offer clients an integrated suite of contemporary marketing services, software, and platforms


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Conduent | Payer digital services profile (page 1 of 2)

Overview








by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

UK

Europe

<US$50

million

Strengths

⚫ Meaningful acquisitions and alliances to strengthen its digital services portfolio

⚫ Sizable presence in mid-sized health plans


⚫ Focus on being more forward-looking and proactive in following industry trends

⚫ Ramp up advanced digital technology-based solutions and deploy in existing

areas of healthcare payer engagement



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Conduent | Payer digital services profile (page 2 of 2)

Overview


Solution Details

Digital transformation

solutions

It provides end-to-end solutions for all operational towers including claims processing, membership and billing, provider maintenance, and

eligibility

Care management

solutions

It includes customized large-scale modeling, profiling, health risk prediction, and data-driven management solutions to improve healthcare

delivery and quality, promote medical best practices, and reduce cost

Credit balance solutions It provides comprehensive reviews of all open credit balances on each provider’s accounts receivable systems and records



Health Solutions PlusAcquisition

In 2019, acquired Health Solutions Plus, a software provider of healthcare payer administration solutions, to better serve

current and prospective commercial and government payer clients with core administration processing technology

Change HealthcarePartnership

In 2019, Conduent integrated the Change Healthcare Medical Review Service into its own Midas Care Management

application to receive medical reviews completed automatically and supported with data pulled from electronic health

records

Innovation centerInvestment

In 2019, launched Innovation Center at Conduent’s corporate headquarters in Florham Park, New Jersey, to develop

and deploy tailored and industry-specific solutions leveraging AI, automation, blockchain, cognitive, data analytics, and

mobility capabilities

Midas Hospital Risk

Assessment Model

Innovation &

solutions

In 2017, released the Midas Hospital Risk Adjustment Model for providing analytical data to healthcare providers to

assist them to self-evaluate their health outcomes and improve care


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DXC Technology | Payer digital services profile (page 1 of 2)

Overview

Scope of digital services for Payer digitals

Cloud, big data and analytics, social media, mobility, cybersecurity, and IoT






by subvertical


Healthcare Payer digital services delivery map

Healthcare Payer digital services revenue

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Canada

Philippines

China

Vietnam

Brazil

<US$50

million

Ukraine,

Belarus

UK

Australia

Mexico

Malaysia

Russia

Thailand

Egypt

FranceSpain

Germany

Sweden

>US$150

million

US$100-US$150

million

Strengths

⚫ Payer-specific and healthcare-dedicated digital solutions across all technologies

such as cloud, analytics, AI, IoT, and automation

⚫ Acquisition of Luxsoft and Molina Medicaid bolsters position in digital strategy

and health services, and enhances Medicaid pedigree


⚫ Enhance meaningful digital consulting engagements with payer clients to

establish strategic partnership opportunities for leading digital transformation

⚫ Create offerings for mid-sized payers to improve market penetration and

reinforce healthcare position in the market



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DXC Technology | Payer digital services profile (page 2 of 2)




Luxoft Holding, IncAcquisition

Acquired a global-scale digital innovator with differentiated offerings, deep vertical industry expertise, and world-class

digital talent.

Azure Practice Partnership Partnered to co-invest in the development of products and services built for Azure.

Molina Medicaid

Solutions ("MMS")Acquisition

Acquired a Medicaid Management Information Systems business.

Tribridge Acquisition Acquired Tribridge to extend DXC Eclipse Microsoft Dynamics SI position and included the Health360 product.

PwC AlliancePartnership

Partnered to provide strategy & consulting services for healthcare customers including digital transformation, cloud,

and GDPR services.


Solution Details

DXC Payer Portfolio It is a comprehensive collection of modular business components to address the state Medicaid business functions

DXC Xuber Health™ It is an agile, enterprise-wide solution for end-to-end business processing, including CRM, global underwriting, accounts, and

claims for a wide range of health insurance product lines as well as supporting both group and individual health-related policies

DXC Health360 It provides personalized care experiences to members by leveraging CRM processes and tools.

DXC Care Coordination

Service

These are BPS underpinned by products and tech that address referral management, complex care coordination, discharge

management, and patient access, which together provide a single point of coordination for all aspects of a patient’s care journey

DXC Open Health

Connect

It is a digital health and analytics platform that delivers the speed, scale, flexibility, and continuous innovation needed to gain

value from healthcare data including internet of (medical) things data and other social determinants

DXC Patient-Driven Care It is a solution that provides a single, persona-based view of a patient’s health and treatment history that connects health

information across multiple systems, practices, and infrastructures; and aggregates it into a single patient record.

DXC Luxoft Blockchain

Patient Engagement

It is a solution that uses blockchain technologies for trusted patient engagement

DXC Payer Digital

Services

DXC offers healthcare cloud, analytics, cloud & platform services, IoT, Bionix, and enterprise and cloud application services. DXC

Bionix uses analytics and AI, lean processes, and leading automation capabilities to produce greater insight, speed, and

efficiency across the end to end value chain


EGR-2019-45-R-348559

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emids | Payer digital services profile (page 1 of 3)

Overview


Digital engineering (agile, DevSecOps), big data & analytics, cloud, mobility,

automation/RPA, AI/ML, SaaS platform modernization, IOT, cybersecurity, UX,

digital IT and operations consulting, VR/AR, blockchain






by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

Strengths

⚫ Healthcare expertise and focus on digital technology offerings across payer

value chain.

⚫ Agile work methodology and nimble response ability for customer needs

⚫ Healthcare domain-specific expertise and specialization


⚫ Focus on engaging in and striking long-term strategic engagement with payer.

⚫ Invest in staying ahead of regulatory compliance changes

⚫ Scalability of talent is cited as a key area of improvement by clients



EGR-2019-45-R-348560

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Solution Details

ADMP (Advanced Big

Data Platform)

It is a healthcare big data platform for payers with advanced open source technologies including out-of-the-box data lake ingestion and

egestion engine and canonical data models with data dictionaries for payer functions such as product development, policy servicing, network

management, care management, and claims management that reduces big data implementation effort by 60% and improve time to market by

40%

Data governance &

quality

It is a proprietary data governance framework that helps payers manage both structured (claims, provider, eligibility, enrollment, etc.) and

unstructured (social media, customer interactions, etc.) data

Blockchain provider data

management

It is a distributed ledger based single source of truth solution to record and maintain an immutable record of the provider across the continuum

to improve provider data accuracy and reduce transaction costs from shared data

Payment integrityIt consists of 85 pre-built FWA algorithms covering claims pre- and post-processing across commercial, Medicare Advantage, and Medicare

part D

Quality reporting and

analytics

It is a robust rule engine that ingests a variety of data such as claims, survey data, call center data, and EHR data from heterogeneous

sources and calculates HEDIS measures. It provides dashboards that help payers with HEDIS quality measure trends and supports multi-

tenancy

Member engagement

analytics

It is a proprietary framework to help improve engagement effectiveness and enhance return on medical dollar spent across all engagement

channels

AI enabled self-serviceIt is a service that is made of AI-powered chatbots for member, patient, provider, and employee self-services. It integrates with core payer

systems including claims, benefits and care management systems to deliver hi-touch and secure services

AI solution for

behavioral health

It is an AI-enabled engagement solution to collect patient data and deliver self-guided digital therapies and telehealth sessions through

coaches

CoreSuite - a clinical

data platform

It is an ONC-certified platform with extensive clinical data repository. It provides tested and robust clinical data model and architecture to

accelerate analytics initiatives using EHR data

PONTEM® It is an IoT enabled on-demand platform that integrates data from devices and applications to deliver point of care or service insights




EGR-2019-45-R-348561

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FlexTech

Alliance

Partnered to develop and implement joint solutions on industry leading payer core administration and population

health management systems

HealthEdge Formed strategic partnership for core administrative system implementation, support and product development

SalesforceFormed strategic partnership to develop multiple joint solutions leveraging emids proprietary platform products and

assets along with Salesforce platform

Google Partnered to develop joint solutions in the areas of AI, ML, big data and advanced analytics

Amazon Web Services (AWS)Partnered to provide reliable, scalable, and inexpensive on demand cloud computing advisory and enablement

services to its customers

LumiataFormed strategic partnership to deliver AI based solutions for breakthrough cost and population health risk

management

Automation AnywherePartnered to leverage RPA platform for automation across the Payer value chain with prebuilt use-case based IP

solutions

UiPathPartnered to leverage RPA platform for automation across the Payer value chain with prebuilt use-case based IP

solutions

John Hopkins Healthcare

SolutionsPartnered with John Hopkins Healthcare solutions to access ACG's licensed platform for clinical analytics

ADMP (Advanced Big Data

Platform)

Investment

It is a healthcare big data platform for payers with advanced open source technologies including out-of-the-box

data lake ingestion and egestion engine and canonical data models with data dictionaries for payer functions such

as product development, policy servicing, network management, care management, and claims management that

reduces big data implementation effort by 60% and improve time to market by 40%

ServiceNow - Appeals &

Grievances App

Invested in ServiceNow appeals and grievances cloud-based app to automate process, improve turnaround time,

reduce provider abrasion and regulatory penalties due to non-compliance

Digital Assistant ChatbotIt is a HIPAA compliant conversational intelligence chatbot that provides engaging, interactive and responsive

experience


EGR-2019-45-R-348562

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EPAM | Payer digital services profile (page 1 of 2)

Overview








by subvertical




Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Ukraine,

Belarus

Russia

>US$150

millionUS$100-US$150

million<US$50

million

Strengths

⚫ Entering into partnerships and developing talent to enhance digital capabilities,

especially in RPA and for cloud initiatives

⚫ Strong focus on value-based care and vision for changing the landscape of care

management in the payer value chain


⚫ Leverage EPAM's digital technology skills in broader areas for extending more

payer-specific solutions

⚫ Invest in building domain expertise for bringing stronger consultation expertise

and position itself as a digital transformation partner



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EPAM | Payer digital services profile (page 2 of 2)

Overview


Solution Details

Big data accelerator It allows enterprises to scale their big data operations using data analytics, platform, and other components. EPAM has set up a Healthcare

Big Data Accelerator to help clients leverage data and generate insights

Application development

and maintenance

The company develops various applications for claims, enrollment, case management, and clinical effectiveness. It also uses analytics and

big data in the field of population health management

Indigo ELN v2.0 It is an open-source electronic lab notebook that helps create, store, retrieve, and share electronic records of chemistry information in ways

that meet all legal, regulatory, technical, and scientific requirements



UiPathPartnership

In 2019, became diamond global partner with UiPath, an enterprise RPA software company, to increase efficiencies and

improve customer experience by leveraging AI solutions and UiPath’s RPA platform

Google Cloud Platform

(GCP) certificationInvestment

In 2019, trained 900 employees on GCP certification

Oneview Healthcare

Partnership

In 2018, partnered with Oneview Healthcare for its digital patient engagement tool and to leverage its digital platform

engineering capabilities

Capital District Physicians'

Health Plan, Inc. (CDPHP)

In 2018, partnered with CDPHP to launch a provider portal to effectively manage patient care, claims, and patient data

Sitecore In 2007, partnered with Sitecore, a global player in customer experience management; has entered into an alliance with

EPAM Systems. This alliance will help EPAM to expand its base in China, Singapore, Hong Kong, and Australia


EGR-2019-45-R-348564

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HCL Technologies | Payer digital services profile (page 1 of 2)

Overview


Cloud, big data and analytics, social media, mobility, RPA, cybersecurity, and IoT






by subvertical


Healthcare payer digitalservices delivery map


>US$150

million

US$50-US$100

million

<US$50

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

Strengths

⚫ Strategic focus on business opportunities from large payers

⚫ Investing in upskilling its digital talent and enhancing digital capabilities,

especially in data analytics


⚫ Focus on positioning as strategic partners through a consultative-led selling

approach

⚫ Delivery teams can be more proactive in bringing cross-sell opportunities to the

clients



EGR-2019-45-R-348565

®


Overview


Solution Details

HIP - Healthcare kit It is an unified solution for data integration and transformation with the ability to integrate various forms of data – pre clinical, clinical,

lab, structured and unstructured data in multiple formats and versions like EDI, HL7, FHIR, NCPDP, etc.

HC data aggregation and reporting

platform

It is a Healthcare data aggregation and reporting platform that helps payers aggregate clinical and non-clinical data from various

sources for consumption of analytics and reporting

hDigix It is a platform that understands and influences how patients engage with their care givers / payers and improves patient outcomes

hSmart IoT Suite It focusses at developing IoT solutions aimed at reducing administrative inefficiencies and enabling efficient member and

physician engagement to help plans shift towards value based care

hSecure It is a modular and business ready security solution that suites varied needs of different sizes of healthcare organizations

Digital business process monitoring It is uses iControl to monitor and highlight the health of Technical and Business processes for payers (Claims and Enrollment)

hCloudJourney - Cloud Adoption

suite

It is a end to end platform to assess application landscape, perform application treatment (refactor, rehost and retire) to migrate

applications to cloud

CoTrust for Healthcare It is a blockchain solution for patient engagement built on the HCL’s CoTrust Platform (HCL's block chain platform), solution focuses

on enabling compliant and secure data management leveraging blockchain

Patient/member engagement

management

It includes components such as SVOC (customer-centric analytics), price transparency, provider identification, health plan

suggester & needs analyzer, Campaign-as-a-Service (CaaS), and campaign orchestration services

Next Gen Population Health

Management (PHM)

It incorporates information, intelligence, and interaction. Adopts a three-pronged strategy across a 360° view of the patient,

analytics-driven care interventions, and patient engagement to enable personalized cure and treatment

Zero Touch Provider Credentialing

Platform

It is a proprietary primary source verification platform that enables health plans to automate provider credentialing across health

systems

Enrollment Automation Solution It leverages ML, AI, and NLP for automated data extraction, which is followed by data processing and automated enrollment

Prospect to Enrollee Solution It automates group renewal business, offering seamless digital experience and reduced costs

MS dynamics based CRM solution It helps payers manage member maintenance activities

HCL Technologies provides other claims management solutions such as ICD services, Claims BPM & Claims BPR, data management, customer service, actuarial

underwriting, dental claims processing platform, Medicare, Medicaid, and other government-funded programs related to claims management


EGR-2019-45-R-348566

®



Strong Bridge Envision

Acquisition

In 2019, acquired SBE, a digital consulting firm specializing in customer experience strategy, business transformation,

and change management

Actian In 2018, (HCL Technologies and Sumeru Equity Partners) acquired Actian Corporation to leverage its healthcare

integration platforms, a web-based deployment manager and self-service administration tool, to integrate disparate data

in a cost-effective, standards-based, and real-time manner

C3i In 2018, acquired C3i a multi-channel customer engagement services provider, specializing in global, high-touch

consumer, patient, and end-user management

BigFix In 2018, acquired the end-point management and security platform that identifies and provides accurate, real-time

information about end-points

AppScan In 2018, acquired the dynamic analysis testing tool designed for security experts and pen-testers to use when

performing security tests on web applications and web services

DataWave In 2017, acquired DataWave to build IP and strengthen capabilities in the digital space

Power Objects In 2015, acquired Power objects, an organization Microsoft Dynamics 365 based solutions that help payers in their

digital transformation journey by bringing together people, data, and processes to better enable personalized care

Diameter Health

Partnership

In 2019, partnered to leverage solutions for normalizing and enriching clinical data using scalable and secure

technology deployable

Fitango Health In 2019, partnered to leverage patient-centric, end-to-end, and integrated Care Delivery Platform for chronic care and

oncology, focusing on improving outcomes in a value-based environment

ClearDATA In 2018, partnered to gain access to Healthcare-as-a-platform, a secure, compliant, and managed cloud platform

exclusively for healthcare and powered by AWS

myElth In 2019, partnered to leverage mobile application that allows real-time medical coverage access and is HIPAA and ONC

(Office of the National Coordinator) certified

CareCentra In 2019, partnered to leverage AI-based solutions to shape member behaviors in chronic, acute, and preventative care

settings

Oracle Health Sciences In 2019, partnered with Oracle Health Sciences to help life sciences companies reduce the cost and time of new drug

development


Overview


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Hexaware | Payer digital services profile (page 1 of 3)

Overview








by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

Mexico

Australia

Strengths

⚫ Strong focus on tackling challenges to help improve customer/patient

engagement and lower costs


⚫ Focus on expanding their services outside North America

⚫ Diving deeper into their existing accounts to leverage cross-sell opportunities



EGR-2019-45-R-348568

®


Overview


Solution Details

RPA-led Payer BPaaS It automates and optimizes processes using RPA bots and IA using ML/AI capabilities

Digital Engagement It enables digital engagement by utilizing pre-built engagement components and enhancing self-service capabilities. It predicts and tracks

member lifetime value, engagement and claims analytics, and a member 360° view

Upgrade Core Admin

System

It replaces core with cloud-based lego block components and integrates new components using microservices-based architecture to augment

existing platform capabilities

hFraud It uses different analysis methodologies to detect and prevent fraud in the claims management cycle

Population Health

Management solution

It is a suite of services that provides services such as population segmentation, regulatory compliance, utilization management, and health

analytics to enable better care management

CarrotCube care

management

It is a care co-ordination clinical portal that can showcase a 360-degree view of the patient and can be leveraged by the entire care team to

manage chronic patients, collaborate amongst each other, and undertake patient outreach

Cloud-based core

administration platform

It is a core upgrade solution for payers for conceptualization, artifact creation, and analyst discussions


EGR-2019-45-R-348569

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Overview



MicrosoftPartnership

In 2018, partnered with Microsoft to facilitate cloud adoption by enterprises across geographies by leveraging Azure, a

Microsoft cloud platform

Zynx HealthPartnership

In 2018, partnered with Zynx Health, a part of the Hearst Health network. The collaboration will involve integration of Zynx

Health's managed care services for evidence-based and vital interventions, clinical workflows, and care-coordination with

Hexaware's CarrotCube population health management platform

CarrotCubeLaunched a suite

(investment)

In 2018, launched CarrotCube, a suite of tailor-built solutions to shift to new models that operate as the basis for Population

Health Management (PHM) that creates a 360-degree view of the patient’s medical profile. The solution is built on Salesforce

Health Cloud that leverages new cloud platforms and connected consumer devices

Innovation lab Investment In 2017, set up customer experience lab to showcase the capabilities in mobile, digital engagement, blockchain, and VR/AR

Oracle HCM Cloud

implementation

services

Launched a

service

(investment)

In 2017, launched package-based Oracle HCM Cloud implementation services that feature a navigation tool with a self-

service portal to help customers select and provision their preferred service package


EGR-2019-45-R-348570

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HTC Global Services | Payer digital services profile (page 1 of 2)

Overview








by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

Malaysia

Strengths

⚫ Provides mobile-based healthcare solutions with a focus on preventive health

⚫ Solutions for centralized data repositories for enterprises

⚫ Investment in Malaysia to allow for better presence in the region


⚫ Requires scaling up investment in digital technology capabilities and

improvement in breadth of solutions for healthcare

⚫ Improve client coverage through service/products portfolio and build domain

expertise



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HTC Global Services | Payer digital services profile (page 2 of 2)

Overview


Solution Details

Enterprise data hubs It consolidates data from disparate systems, reduces reporting cycle times, and enables effective information exchange across the

organization and beyond

Health Savings Accounts

(HAS) solution

It is an estimator tool that educates members on the cost of each healthcare service they plan to obtain, to enable making well-informed

decisions on the amount to be allocated for each health requirement

ICD10 solution framework It migrates tools and products to calculate the impact analysis and determinate crosswalks. The conversion and testing framework helps

expedite and complete the conversion efforts

mHealth solutions It enables healthcare organizations to create a new model for healthcare access, payment, and delivery. The healthcare provider search

features on the mobile allow patients to locate physicians, pharmacies, and hospitals even on the move or during emergencies



New officeInvestment

In 2019, opened a new office in Kuala Lumpur, Malaysia, to grow in the region and to provide consistent client

relationships and delivery excellence

Automation Anywhere Partnership

In 2018, partnered with Automation Anywhere to enhance RPA services by developing bot-based industry-specific

solutions. These solutions included abilities such as speech recognition, NLP, and ML to automate perceptual and

judgment-based tasks

IntelledoxPartnership

In 2018, partnered with Intelledox, a global software provider, to provide system integration, analytics, and technical

support to enterprises by leveraging the Intelledox Infiniti platform

Ciber Inc.Acquisition

In 2017, acquired Ciber Inc., a global IT consulting services and outsourcing company, to enhance the organization's

ability to deliver superior customer service, technologies, and relationships


EGR-2019-45-R-348572

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IBM | Payer digital services profile (page 1 of 3)

Overview


Cloud, big data and analytics, social media, cybersecurity, RPA, blockchain and

IoT






by subvertical




US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Canada

Philippines

China

Vietnam

Brazil

>US$150

million

<US$50

million

Strengths

⚫ Superior cloud and AI analytics capabilities in digital transformation

engagements with some of the larger existing payer accounts

⚫ New formed alliance with Cigna and Sentara Healthcare brings IBM to the

forefront of exploring application of blockchain in healthcare


⚫ Improving market impact through better integration of Watson Health, which has

faced issues in terms of commercialization of sizable investments and

highlighting more use cases for payers

⚫ Build better coordination and synergy of workflow between discrete service lines



EGR-2019-45-R-348573

®


Overview


Solution Details

IBM Watson Health value-

based care solutions It integrates the specialized capabilities of Watson Care Manager, Truven Health Analytics, Phytel, and Explorys. It combines patient-level

data from a variety of sources including Electronic Health Records (EHR), hospital administrative and clinical databases, and claims data to

develop a deeper understanding, and help predict future needs and behaviors

IBM smart analytics system It provides broad analytics capabilities on a warehouse foundation with IBM server and storage; the solution gives health insurance

companies off-the-shelf, predictive analytics

IBM health plan data model It contains data warehouse design models, business terminology models, and analysis templates that accelerate business application

development

IBM transformation

accelerator and manager

for ICD-10

It is a software package that interfaces with existing systems and applications; includes tools for defining, managing, and testing ICD-9 to

ICD-10 transformation & exception processing, and analytics & collaboration services

SleepHealth It is an application built on IBM Watson Health Cloud, for iPhone and Apple Watch, to collect data on sleeping habits and analyze their impact on

health

IBM Watson Health It provides cloud-based access to Watson supercomputer for analyzing health-related data spanning specific life sciences modules


EGR-2019-45-R-348574

®


Overview



Cigna and Sentara

Healthcare

Partnership

In 2019, partnered with Cigna and Sentara Healthcare to join IBM blockchain initiative to explore ways that blockchain

can be used to address a range of industry challenges

Qualys In 2019, partnered with Qualys to provide improved visibility of IT assets, vulnerabilities, and threat data to its clients

SmartAnalyst In 2018, partnered with SmartAnalyst to provide them clinical data that helped them to market its medications by using

IBM Explorys

Quest Diagnostics In 2017, partnered with Quest Diagnostics to offer genomic sequencing and cognitive computing capabilities to patients

in the US

MAP Health Management In 2017, partnered with MAP Health Management’s MAP Recovery Network Platform to enhance the platform's existing

capabilities around patient risk models

Atrius Health In 2017, partnered with Atrius Health to develop a cloud-based service designed to improve the physician-patient

experience

Innovation center

Investment

In 2017, IBM Canada launched an innovation center in Hamilton, Ontario, Canada, in partnership with Hamilton Health

Sciences. The facility will serve as a platform for local entrepreneurs, researchers, and healthcare professionals to

collaborate on projects that will help improve the delivery of healthcare globally

Health center In 2017, started IBM Watson Health center in Helsinki, Finland, to enhance innovation and collaboration, and to fast-

track healthcare solutions in the country


EGR-2019-45-R-348575

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Infosys | Payer digital services profile (page 1 of 2)

Overview


Cloud, big data and analytics, social media, cybersecurity, RPA, mobility and IoT






by subvertical




Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

China

<US$50

million

US$100-US$150

million

>US$150

million

Strengths

⚫ Strong relationship management and delivery talent

⚫ Expansive digital technology engagements in multiple domains

⚫ Extensive network of healthcare engagements with large national plans and

Blues


⚫ Improve and emphasize healthcare branding and messaging

⚫ Establish distinctive differentiation by bringing larger IP and platform play

⚫ Leverage existing reach within IT legacy engagements in payer verticals for

developing digital roadmaps and specific digital solutions



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Infosys | Payer digital services profile (page 2 of 2)

Overview


Solution Details

Infosys Nia An AI platform that collects and aggregates organizational data from people, processes, and legacy systems into a self-learning knowledge

base and then automates repetitive business and IT processes

Infosys AssistEdge Customer service platform to provide a single view of service and self-help to consumers. The platform integrates payers with the provider’s

product-based systems

Infosys Benefits Enquiry

Chatbot

The solution leverages the Infosys Nia IKP platform to extract and build ontology models that can be leveraged to address common natural

language enquiries around plan benefits and prior authorizations

Infosys SFDC CarePLUS

solution

The care platform built as a service on Salesforce.com enables payers to connect better with healthcare consumers by providing a 360° view

of every consumer through personal health tracking tools and monitoring devices

iHawk-Eye Auto-

Adjudication (RPA) Engine

The insights-driven automation and process performance monitoring and management platform supports cross-functional processes such as

pending claims processing for optimization at reduced operational costs / manual overheads

Clinical Quality and

Compliance Management

Solution

It provides advanced levels of clinical and business process efficiency in real-time to improve quality of care and adherence to processes in

the hospital



Google Cloud

Partnership

In 2019, partnered with Google Cloud to offer industry-specific solutions on Google Cloud Platform for healthcare

Multiple partnership In 2018, partnered with Rhode Island School of Design, Siemens, Astound, A.S. Watson Group, and Purdue University,

among others, to leverage their cognitive, IoT, and AI capabilities to develop solutions in the healthcare space

WONGDOODY Acquisition In 2017, acquired Brilliant Basics and Skytree to strengthen its digital, cognitive, and analytical capabilities


EGR-2019-45-R-348577

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Mphasis | Payer digital services profile (page 1 of 2)

Overview


Cloud, big data and analytics, social media, mobility, cybersecurity, and IoT






by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

Canada

Sri Lanka

Latvia

Strengths

⚫ Single cloud-based platform for all value chain elements, with special focus on

automation

⚫ Focus on the use of analytics including AI, for data preparation, claims

processing, and unified consumer experience across communication channels


⚫ Needs more proof points to demonstrate its transformational capabilities across

payer vertical

⚫ Clearly articulate value proposition to highlight its breadth of offerings across

products and services



EGR-2019-45-R-348578

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Overview


Solution Details

Care management solution It is a part of consulting service that facilitates the determination of future digital strategy to support transformation of care management and

wellness services

Claims management

solution

It is a cloud-based solution supporting efficient claims automation and management. It facilitates pricing, benefit determination, auto

adjudication, workflow, and other supporting components

Javelina It is a cloud-based solution and has more than 20 integrated components that facilitate product support in multiple areas such as pricing and

billing component. These components are utilized for management and modeling of plans by product configuration and data access

Network management

solution

It is a platform that provides management of data, network administration, contract definitions including fee schedules, hospital contracting,

value-based contracting, and network integration

Policy servicing and

management solution

It is a core hosted platform providing enterprise cloud-based policy servicing. It includes components for efficient management of claims,

billing, documents, customer service, and other health-related insurance policy management functions


EGR-2019-45-R-348579

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Overview



StelligentAcquisition

In 2018, acquired Stelligent to leverage its cloud automation capabilities that resulted in reduction in deployment time by

97% and in workload time from six hours to seven minutes

Sparkle innovation

ecosystem

Investment

In 2017, invested in sparkle innovation ecosystem that leveraged disruptive start-ups, meticulous research compiled by

academicians, innovations, and frameworks posted by practitioners from various industries, economies, and geographies

globally. It included:

⚫ Sparkle labs: It is the channel between enterprises for legacy as well as digital native and disruptive start-ups

⚫ Sparkle accelerator program: It brings together top educational institutions, consulates, and industry bodies to discover

cutting-edge technologies, software, and frameworks

⚫ Sparkle co-creation hub: It is an innovation factory for customized solutions, prototypes, and pilot disruptive solutions

created for strategic clients

Autocode AIInvestment

In 2016, invested in Autocode AI to automate the design that facilitates code development process which reduces time, cost,

and effort to go from requirements to code

DeepInsightsInvestment

In 2016, invested in DeepInsights, a patent-pending platform that enables enterprises to gain faster and effective access to

insights from data

InfraGenie™Investment

In 2016, invested in InfraGenie™, an integrated service management and automation platform that delivers response to

service requests, provides integrated dashboards, reduces manual intervention, and optimizes cost of operations

InfraGrafInvestment

In 2016, invested in InfraGraf®, an event processing engine that enables enterprises to innovate and make strategic

decisions about their technology infrastructure through actionable insights by correlation and relationship analysis of data

HyperGrafInvestment

In 2015, invested in HyperGraf to generates insights by bridging the gap between enterprise, external, and third-party data

such as social media, credit scores, open data, and other multimedia datasets

El Dorado Acquisition

In 2005, acquired El Dorado to strengthen footprint in the US and enter healthcare insurance and payment processing

business by leveraging its payer platform and enterprise automation capabilities


EGR-2019-45-R-348580

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NTT DATA | Payer digital services profile (page 1 of 3)

Overview


Mobility cloud, data and intelligence, social media, cybersecurity, automation, IoT,

telehealth and virtual care, database platform as a service, advanced analytics






by subvertical



Healthcare Payer digital services revenue

>US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Mexico

Philippines

<US$50

million

US$100-US$150

million

Strengths

⚫ Strong platform play with a focus on end-to-end services

⚫ Strong focus on business-first approach rather than just offering technology

solutions


⚫ Ramp up capabilities outside North America

⚫ Expand its digital services by embedding next-generation technologies and

services across its legacy relationships



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NTT DATA | Payer digital services profile (page 2 of 3)

Overview


Solution Details

NTT DATA Business

Insights Engine

It is a a multi-modal next generation data and intelligence platform that has a flexible data stack to allow clients to incrementally add data

regardless of data type (structured, unstructured, etc.) & formats

NTT DATA Connected

Health

It is a solution that provides great flexibility to caretakers (such as an RN) or operational monitoring staff (such as a safety officer), including

custom health thresholds, views, and charts/diagrams. In addition, the community messaging functionality is available allowing for real-time

messaging to a specific monitored individual or the entire community.

Provider Data Management

Solution

It is an end to end solution to increase the quality and effectiveness of provider network data to reduce the overall cost of care. It includes:

provider engagement-claims, eligibility, benefits, autos, workflow, notifications, etc., provider data management-data cleansing, workflow,

golden record, contracts, etc.

NTT Data Robotic Context

Processor

It is a cognitive automation engine that utilizes built-in optical character recognition and natural language processing technology for

comprehending complex legal documents to resolve onboarding challenges faced by the healthcare industry

Health plan payment

integrity solution

It provides toolsets for screening, scoring, and coordinating benefits to detect fraudulent claims and improve payment integrity

Enrollment and billing

solution

It is an open architecture, cloud-enabled integration solution enabling secure, real-time, quality transactions between health plans, providers

and Federal/State systems. This solution is offered for private exchanges and can be implemented as an on-premises or cloud-based tool for

core enrollment and billing functions

Integrated NTT DATA

statistics tool

It provides capabilities to create ‘What-if’ analysis reports, check business rules/regulatory compliance, and reduced validation/test efforts by

using Premium Quote data spreadsheets

Social Media NTT DATA can help clients build their brand with a social media presence and help promote their portal and their brand with social media

channels. NTT DATA is an industry leader in using social media to engage with and understand consumers. We can help with social media

strategy development, a listening command center, and consulting to help clients make effective use of social media channels

NTT DATA Nucleus It is a cloud-based intelligent enterprise platform, which brings together NTT DATA’s analytics, processes and operations into a single

foundation to accelerate innovation for clients.

Healthcare digital

consumer solutions

It covers Program Strategy & Design Services, Clinical Consulting Services, Digital Engagement Services, Technology Services, Care

Support Services (BPO) services. Customer/User Experience (CX/UX) Consulting. It includes member and provider engagement, member

mobile application, shopping/enrollment, broker, employer, & employee portals


EGR-2019-45-R-348582

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NTT Data | Payer digital services profile (page 3 of 3)

Overview



Multiple partnership

Partnership

In 2016, Codebaby (Idavatar) partnered with NTT DATA consumerism solutions to leverage their virtual avatar

solutions and services

Healthcare Blue Book In 2016, partnered with Healthcare Blue Book to leverage its cost transparency solutions and services

Google In 2016, partnered with Google to leverage its maps and web analytics solutions and services

App Dynamics In 2016, partnered with App Dynamics to leverage its application monitoring solutions and services

Alfresco In 2016, partnered with Alfresco to leverage its document management solutions and services

Umbraco In 2016, partnered with Umbreco to leverage its web content management solutions and services

Microsoft In 2016, partnered with Microsoft to leverage its application platform and database

NTT DATA’s Connected

Wellness Health Investment

In 2016, launched NTT DATA’s Connected Wellness Health to bring extended research and development efforts in

emerging technologies, such as connected healthcare wearables, robotics, and artificial intelligence

NTT DataSense – IoT

Analytics Platform

In 2016, launched NTT DataSense – IoT Analytics Platform combined with deep expertise in IoT technologies to

enhance customer experiences across industries


EGR-2019-45-R-348583

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Optum | Payer digital services profile (page 1 of 3)

Overview


Cloud, big data and analytics, social media, cybersecurity, blockchain, RPA and

IoT






by subvertical




Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Ireland

Philippines

<US$50

million

US$100-US$150

million

>US$150

million

Strengths

⚫ Valuable UnitedHealth Group (UHG) pedigree and strong product base provides

distinct edge in the healthcare domain

⚫ Exhibiting strong thought leadership with regards to impact of emerging digital

tech on healthcare


⚫ Improve communication across teams within the organization, aligned to the

same client and project



EGR-2019-45-R-348584

®


Solution Details

Rally Rally consists of digital solutions that attract and sustain the member’s life-long engagement in healthcare, while serving the health plans’

goals for growth in the marketplace through member acquisition and member retention. Consumers gain access to the full value of the health

plan, with a unified, personally relevant digital experience that connects the consumer to each plan’s assets.

StepWise suite It is a software platform that simplifies design, deployment, and distribution of health insurance products across stakeholders and businesses

Optum Performance

Analytics

It is an analytics platform, powered by OptumIQ, that weaves together clinical and claims data assets with a set of social, demographic,

behavioral, patient-reported, and quality outcomes data to give a comprehensive view of each patient, provider, and facility

Individual Health Record

(IHR)

It is a patented, dynamic, easy-to-use longitudinal accounting of each individual’s historical health and current health status. It offers people

and clinicians secure access to personalized health information through desktop or mobile applications

Payment Innovation The solution manages provider networks and drive growth while controlling administrative expenses. It help payers with network

administration, contract and fee schedule activity tracking and management, fee-for-service pricing administration, and automated high-

volume claims pricing, validation, and routing

Risk & Quality Gap

Management Portal

An easy-to-use tool that enables the providers in a payer’s network to see a comprehensive view of their patients across multiple health plans

engaged with Optum. It is flexible, so providers can choose how to integrate it within your existing workflows

Impact Intelligence® It leverages Optum Symmetry®, a foundational analytics suite for assessing cost, risk, and quality, to show complete retrospective views of

members and provider networks, including utilization, referral patterns, cost, and physician performance

Condition Management The program helps better manage conditions such as heart failure, chronic obstructive pulmonary disease, asthma, coronary artery disease,

and diabetes by leveraging the robust data and analytics that builds a holistic view of each individual

Medical Benefit

Management

An integrated suite of services to help health plans manage organizational risk and reduce unnecessary treatments and hospitalizations in

order to lower costs, increase overall member satisfaction, and improve outcomes for members facing the complex medical conditions

Optum Care Coordination

Platform

It empowers health plans to manage member care proactively and intelligently across the health care ecosystem, prioritizing interventions,

and allocating resources for at-risk individuals, improving clinical and financial outcomes, enhancing the member experience, and efficiently

scaling population health initiatives throughout their organizations

PreCheck MyScript™ The solution simplifies prescribing experience for members and physicians by providing real-time, member specific medication pricing and

coverage information plus formulary specific alternatives at the point of prescribing, embedded within the prescribers' existing EMR workflow

MyScript Finder™ The solution addresses the need for an improved consumer price and benefit transparency tool for 55 million members

Payment Integrity Consulting, technology and services to transform end-to-end claims processing performance

Optum Medicaid

Management Services

Comprehensive management of Medicaid Fee for Service populations delivered through a modular, services-based, multi-tenant platform.

The modules provide all Medicaid business functions including EDI, Encounter Processing, Claims Administration etc.


Overview


EGR-2019-45-R-348585

®



Equian

Acquisition

In 2019, acquired Equian to expand the services and solutions Optum offers to the market, strengthening existing Optum

relationships with health plans, government agencies, and providers, while also enhancing Equian relationships in areas

adjacent to health care such as property & casualty and workers’ compensation

Advisory Board Acquisition

In 2017, acquired Advisory Board to strengthen its existing capabilities in industry research, technology, and consulting

services

Atlanta University Center

ConsortiumPartnership

In 2019, partnered on a new initiative to prepare students to meet the growing demand for data analytics experts

Talkspace Partnership In 2019, partnered with Talkspace to provide telemental health application available to its two million customers

Amazon Web Services

(AWS)Partnership

In 2018, partnered to launch an opensource project titled “Disposable Cloud Environments” – an open source solution to

deliver enterprise developer sandbox accounts

Microstrategies Partnership In 2018, partnered to mature the security and compliance offerings of their marketplace offerings

Brown, Parker and

Dumanis (BPD)Partnership

In 2018, partnered to launch consumer-focused digital marketing campaigns for hospital systems

Genomics England

Limited Partnership

In 2018, partnered to leverage software created by Genomics England for broad use in precision medicine. It aims at

creating the capability to sequence both healthy subject and current patient DNA for genomic analytics as a tool to

diagnose and predict disease, as well as refine treatment

Synaptic Health AlliancePartnership

In 2016, partnered to apply blockchain technology to improve data quality and reduce administrative costs associated

with changes to health care provider demographic data

Multiple partnerships

Partnership

Partnered with FICO, Intel Corporation, Health Fidelity, MedeAnalytics, Crossix Solutions Inc, Mi7, Blockchain

Healthcare Alliance, HealthEdge, Microsoft, Medisafe, and Fibroblast, among others, to strengthen its mobility, cognitive,

analytical, and digital capabilities

Optum Ventures

Investment

In 2017, launched Optum Ventures, the sister company to UHC and Optum. Optum has committed US$600 million to

fund digital healthcare firms. Optum Ventures invested in cloud-based platforms such as Apervita, a cloud-based

analytics platform; SHYFT Analytics, a cloud-based pharmaceutical research platform; and Mindstrong Health, that uses

ML to help patients assess their mental health disorders through their smartphones

Advanced Technology

CollaborativeInnovation

In 2016, established a dedicated team focused on incubating emerging and advanced technology through research and

delivery of business solutions and reusable services


Overview


EGR-2019-45-R-348586

®


Cloud, big data and analytics, social media, cybersecurity, and IoT, blockchain,

AI/ML/cognitive, mobility, RPA






by subvertical


Healthcare payer digitalservices delivery map


Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

US$50-US$100

million

<US$50

million

US$100-US$150

million

>US$150

million

India

Ireland

AustraliaUruguay

UK

Europe

PhilippinesMexico

Strengths

⚫ Solutions portrayed a strong healthcare expertise along with a breadth of

services

⚫ Strong business focus on top of the technology play, to act as strategic partner

for clients


⚫ Focus on winning engagements with creative deal constructs such as

gainsharing, as-a-service, and co-investment with clients


TCS | Payer digital services profile (page 1 of 2)

Overview


EGR-2019-45-R-348587

®


Overview


Solution Details

TCS enrollment 360 Enrollment 360 is a digitized platform, which covers end-to-end enrollment stages from onboarding the groups to the insurance card creation,

to address the requirements of entities across the healthcare ecosystem

Analytics-based health plan

framework powered by

blue button

It recommends the best health plan for customers during sales/self-enrollment based on their claim history, EOB, and coverage details

obtained from CMS

TCS provider data

management portals

It is the provider network on blockchain that helps in validating information from primary sources, ensuring a shared source of truth for

validating healthcare provider information

TCS integrated care

delivery framework

It provides integrated care delivery by enabling a 360 degree view of the member, powered by an enterprise data integration platform

TCS value-based care It is a big data platform built based on principals of Interoperability which helps organizations with managing the movement towards new

payment methodologies that are being driven by clinical outcomes and population health

TCS health 360 It is a personalized patient engagement platform focused on virtual care

Patient intake framework

powered by blue button

It caters to both patient intake by provider and patient case registration for payers leveraging Blue Button APIs. It can automatically fetch all

the necessary details from CMS and quickly complete patient registration for a case management plan

Claims denial analytics

platform

It is an AI-powered analytical platform, which provides insights for denied claims or partial payment, thus helping in reducing rework and cost

of providers/payers

Fraud detection and claim

accuracy analytics

It is an analytics model that helps payers to predict any fraud or incorrect claims

Cloud / Security Crystal

Ball for Healthcare

It is a common platform for consent management and data subject rights. It provides seamless integration with minimal changes to existing

infrastructure and is maximum compliance ready. It is customizable for global privacy regulations

TCS Smart Quality

Engineering (SmartQE)It is a AI based platform that offers integrated delivery of quality engineering services. Developed on the principles of ‘integration, intelligence

and automation', smartqe optimizes the QE lifecycle through contextual insights and actionable outcomes

ignioTM for healthcareIt is a cognitive solution to transform siloed and transactional payer enterprises into intelligent, near real-time and end-to-end cross domain

aware enterprises.

Cloud Counsel It is a cloud discovery, assessment and recommendation framework that helps in selecting the most appropriate cloud model and cloud

provider with network, and provides a cloud migration roadmap, cloud-readiness of the applications, ROI, and TCO estimates


EGR-2019-45-R-348588

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Overview



Operating Model

Transformation

Investment

Invested in transforming to a truly agile ways of working and transforming to a PODS based, outcome based model and

moving customers towards location independent agile

Multiple CoEs In 2019, set up Cloud DevOps and IoT labs to execute POCs to evaluate the viability of a product or service to ensure it

meets specific needs or requirements

Healthcare Delivery

Center / Cincinnati

Investments to establish an onshore centric agile delivery center for healthcare to accelerate the transformation in an agile

model at Cincinnati. Initiated programs to reimagine customer experience for one of the BCBS from the center

TCS PaceTM Port In 2019, TCS Pace Port™ launched in New York at the cornell tech campus to tap into TCS research, innovation, and co-

innovation to drive digital transformation

IoT solutions

Innovation &

solutions

In 2019, built Cold Chain with IoT and blockchain, an integrated supply chain with IoT and blockchain platform, and Digital

Twin for Hospital Energy management

Big data and analytics

solutions

In 2019, built Claims Denial Analytics Platform, an AI-powered analytical platform that provides insights for denied claims or

partial payment, helping in reducing rework and cost of providers

Ambient Assisted Platform Invested in a platform that reimagines elder care by empowering senior citizens to lead an independent and dignified

lifestyle by using IOT, AI and other digital technologies

NY Marathon App Investments done to integrate augmented reality into several experiences to surprise and delight runners during the

marathon. Runners had the ability to unlock special messages during the race

Multiple partnerships

Partnership

In 2018-2019, partnered with Cloudera, Hortonworks, MapR, AWS, IBM, Oracle, MongoDB, Tableau, Qlikview, Microsoft,

SaS, Splunk, Snowflake, Marklogic, Salesforce, Pentaho, Talend, and Informatica for big data and analytics

Intel In 2018, partnered with Intel to develop a portfolio of IoT solutions across several areas such as smart cities, smart

infrastructure, connected assets, and telematics

Multiple partnerships In 2018-2019, partnered with GEPredix, Siemens MS, SAP Leonardo, PTC Thingworks, IBM Watson, MS Azure IoT, AWS

IoT, and MindSphere for IoT platforms

Multiple partnerships In 2018-2019, partnered with IBM Watson, Google Machine Learning, H2O.ai, TensorFlow, Databricks, and Maple Imaging

Solutions for AI/CC platforms

Multiple partnerships In 2018-2019, partnered with api.ai, Kore.ai, Watson, Alexa, and Inbenta for conversational platforms

Multiple partnerships In 2018-2019, partnered with UIPath, Automation Anywhere, BluePrism, and Abbyy for RPA solutions and services

Multiple partnerships In 2018-2019, partnered with Websense, NetIQ, Symantec, McAfee, Fortify, HP, Dell, CA, Intel, Veracode, Qualys,

Microsoft, ProDiscover, AccessData, Mandiant, Checkpoint, IBM, Encase, and others for cloud solutions and services

COINTM Scrutinized and listed 1700+ startups from which 29 key startups are identified that could benefit the Healthcare payers


EGR-2019-45-R-348589

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Tech Mahindra | Payer digital services profile (page 1 of 2)

Overview








by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

<US$50

million

US$50-US$100

million

Strengths

⚫ Meaningful partnerships across various field, to enable digitization

⚫ Acquisition of new talent and upskilling of existing talent to battle the ongoing

talent shortage issue


⚫ Integration of various point solutions for an integrated platform

⚫ Focus on bringing more healthcare-specific solutions

⚫ Focus on growing relationships with clients by understanding client requirements

in greater depth and proactively suggesting initiatives



EGR-2019-45-R-348590

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Tech Mahindra | Payer digital services profile (page 2 of 2)




Quantoz Partnership Partnered to enhance software development capabilities to help drive blockchain technology innovation in healthcare

H2O.aiPartnership

Partnered to leverage AI for scenarios including managing claims, detecting fraud, improving clinical workflows, and

predicting hospital-acquired infections

Proprietary solutions for healthcare payer digital services (representative list)

Solution Details

Integrated Wellness

Solution

It is a wellness solution that uses digital technologies to improve member health and reduce cost of care

Digital mail room It is a smart way of handling traditional mailroom operations to reduce cost and increase accuracy

Provider management It is a solution that reduces the enrollment, administrative cost and improves provider relationship time

Medical specialty

Platform

It is a platform to manage member health and benefits through specialty & therapy lines (diabetes, hypertension, pregnancy, etc.)

Digital service desk It is an AI-/automation enabled end-user service desk

WaaS Nxt It is an end-to-end HIPAA-compliant digital workspace platform


EGR-2019-45-R-348591

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UST Global | Payer digital services profile (page 1 of 2)

Overview








by subvertical




>US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

Mexico

Philippines

<US$50

million

US$100-US$150

million

Strengths

⚫ Innovative ways of leveraging existing technology platforms to provide end-to-

end capabilities and business operation services for healthcare

⚫ Meaningful partnerships, acquisitions, and investments to strengthen the digital

play


⚫ Focus on innovative commercial constructs such as risk-sharing model or

outcome-based pricing



EGR-2019-45-R-348592

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UST Global | Payer digital services profile (page 2 of 2)

Overview


Solution Details

SmartOps™ It is an AI-based decision platform to improve the productivity of claims processors. It acts as a virtual SME facilitating enhanced decision-

making by generating knowledge-driven insights from data. It results in cost-savings



HealthMine Partnership In 2019, partnership with HealthMine to enhance member engagement across the care continuum

KPI NinjaPartnership

In 2019, partnered with KPI Ninja to leverage its healthcare and technology expertise to craft a business model that aids

customers in accelerating their capabilities in delivering improved quality and low-cost healthcare services

MyDoc Partnership In 2019, partnered with MyDoc to leverage its end-to-end telemedicine platform

Multiple partnerships Partnership Partnered with PwC, E&Y, and Oracle to explore healthcare insurance platform implementation opportunities globally

Venture capital funding Investment

Invested in start-ups, especially in the healthcare analytics, AI, block chain, and cybersecurity space, that will support health

plans to be co-investors

KaHa Acquisition In 2019, acquired KaHa to leverage its end-to-end IoT platform for wearables and to capture the Singapore market

PneuronAcquisition

In 2019, acquired Pneuron to build a platform by leveraging its capabilities of design, deploy, run, and maintain performance

distributed solutions at half the time, cost, and risk of traditional alternatives

PragmasysAcquisition

In 2019, acquired Pragmasys to leverage CRM implementation offerings to improve business productivity, increase C-SAT,

and reduce IT complexity

COPE health solutionsPartnership

In 2018, partnered to leverage Analytics for Risk Contracting (ARC) suite that provides combined data from claims and

clinical sources in and out of network for a 360-degree view of the provider and member

STARDATAcquisition

In 2018, acquired STARDAT to develop an automated prior authorization process with recommendations on grievance and

appeals

Hilabs Partnership Partnered with Hilabs to leverage its Risk Adjustments and Data Quality platform to support Healthcare payers

Contineo Health Acquisition In 2019, UST acquired Contineo Heath, a leading healthcare technology consulting firm specialized in EHR Optimization

Abzooba Acquisition UST acquired Abzooba to leverage the Healthcare Analytical solutions that is used by many payors in US market

Zipari Partnership In 2017, UST partnered with Zipari to leverage their CX engine built for health plans to support with portal implementations

Health Edge Partnership In 2017, UST partnered with Health Edge for implementation of Bpaas capabilities


EGR-2019-45-R-348593

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Virtusa | Payer digital services profile (page 1 of 2)

Overview








by subvertical




>US$150

million

US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million

UK

<US$50

million

Sri Lanka

Strengths

⚫ Focus on digital services expansion through strategic partnerships and alliances

with BigTech players

⚫ Leveraging design-thinking to understand the payer pain points and covering all

aspects of the payer value chain


⚫ Enhance the thinking of the industry by focusing on thought leadership in digital

engagements

⚫ Improved focus on account management and client relationships



EGR-2019-45-R-348594

®


Solution Details

Provider lifecycle management It is a unified platform that modernizes all aspects of complex provider relationships including prospecting, contracting, onboarding,

credentialing, configuring, and servicing

Contact center solution It is a customer-centric engagement platform that provides a 360-degree customer view. It utilizes emerging capabilities around chatbots

and robotics so that the information is easily accessible to CRSs looking to serve members, providers, and other key stakeholders

Sales automation platform It is a scalable enterprise administration platform designed to integrate real-time with health plan management systems. Key features of

the platform are lead management, opportunity management, opportunity finalization, and renewal automation

Product and benefits

transformation solutionIt is a solution that leverages Accelerated Solution Delivery (ASD) methodology to deliver a unified product repository for a faster go-to-

market strategy and reduce maintenance expenses

Automated billing platform It is a solution that provides customer-centered bill payment options. Its comprehensive feature set serves healthcare providers and

insurers asuch as – ensuring that patient care is paid and premiums collected

HOPE It is an intuitive, integrated, and connected platform powered by AI that provides seamless collaboration among patients, providers, and

payers, while fostering self-service and addressing gaps in the patient journey

Healthcare AnalyticsToAction It is a solution that applies business intelligence to augment performance, manage patient health, and address compliance

vLife vLife™ allows companies to innovate rapidly on a consistent platform, without having to completely re-engineer its IT delivery approach

Virtual AI Lab-as-a-Service It is an offering that allows clients to leverage the innovation team, functional framework, point solutions, accelerators, and integrated

partner technologies to ignite AI/ML initiatives and move from ideation to production



HI-TRUST Certified Certification Our Healthcare and Life Sciences practices have earned HITRUST CSF Certified status for information security by

HITRUST on the following platforms: Active Directory, Endpoints, and Network Devices.

AWS Partnership Partnered as one of two SI partners with a strategic collaboration agreement with AWS, allowing for joint POC funding to

build out cloud- based transformative solutions around connected health, IoT, and large scale data/analytics programs

Legerity Partnership /

joint venture

Partnered with a provider of consulting and implementation services that will help put U.S. Veterans on the front lines of

DPA projects with clients throughout the US. This partnership is centered on helping clients in healthcare utilize the

advanced Pega platform to implement DPA projects, thus improving member, provider, and customer experiences

IBM Partnership Partnered to expand the reach of the IBM Watson Health suite of solutions, leading providers and payers through value-

based care transformation by leveraging data and analytics that are powered by design thinking and automation

Virtusa | Payer digital services profile (page 2 of 2)



EGR-2019-45-R-348595

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Wipro | Payer digital services profile (page 1 of 3)

Overview


Cloud, big data and analytics, mobility, cybersecurity, and IoT






by subvertical




US$100-US$150

million

Adoption by LOBs


Claims management


High (>25%) Medium (15-25%) Low (<15%)

High (>50%) Medium (20-50%) Low (<20%)

High (>30%) Medium (20-30%) Low (<20%)

United States

India

US$50-US$100

million<US$50

million

>US$150

million

Australia

China

Europe

Strengths

⚫ Strong capabilities in digital technologies with a consulting focus

⚫ Strong focus on honing capabilities through acquisitions and bringing the right

talent on board


⚫ Integration of digital consulting and technology capabilities to showcase strong

proof-points and deliver end-to-end engagement with clients



EGR-2019-45-R-348596

®


Overview


Solution Details

HPS ACA Solution Comprehensive Individual Consumer enrolment & billing business solution focused on data integrity, accuracy, quality and compliance

Medicare Advantage 360

Platform

Comprehensive Medicare Advantage platform covering eligibility, member management, reconciliation, broker, risk adjustment,

submission and Appeals and Grievances

Digital Patient Centricity suite It is a suite of solutions to help payers, providers, and other healthcare agencies to deliver patient-centered care across the complete care

life cycle. The suite includes digital patient engagement solutions, glass health, assure health, digital member engagement solution, and

healthcare big data analytics solution

Value Based Care Offering End-to-end value based care(VBC) offering that brings in designing a VBC program, platform for patient health management, care

management, remote monitoring & care co-ordination and analytics as a service

Claims management The company has three claims management systems (addressing Group Business, Medicare, and Medicaid segments) that are deployed

for large commercial payers and state, offering several point solutions for claims management. In addition, Wipro Holmes’s second stage

auto adjudication engine helps automate processing of claims that fall out of the auto adjudication engine

Threat management platform It is an integrated approach to cybersecurity defense system to stay resilient and prevent malicious activities

Connected solution for

diabetes care

It is a mobile health solution using a novel glucose monitoring system, integrated with a cloud-based monitoring application for

providing efficient and effective diabetes care

2nd

Level Auto Adjudication

Engine

Wipro HOLMESTM

based 2nd

Level claims processing engine post auto adjudication stage. Its cognitive engine pro-actively identifies

rework or appeal candidates reducing significant rework.

Inventory Management

Tool/Bot (IMT)

This Wipro HOLMESTM

based tool can auto monitor, assign and process claims inventory

Wipro HOLMESTM

Anomaly

Detection and Contract

intelligence tool

This Comprehensive tool helps in reducing false positives, machine-created rules that adapt to changing business environment, detection

of new fraud schemes and scoring and prioritization of red flags

Wipro HOLMESTM

Fraud,

Waste and Abuse Prevention

Leveraging AI and Advanced Analytics to understand patterns in claims and flag fraudulent claims for further investigation with very high

accuracy levels in the Payment Integrity area

Wipro Medicaid Enterprise

Management System

(MEMS)

It facilitates operations management – claims adjudication & processing, service authorization, and cost avoidance


EGR-2019-45-R-348597

®


Overview



Innovaccer Partnership In 2019, partnered for interoperability and healthcare analytics

Medversant Partnership In 2019, partnered to leverage provider lifecycle management solutions

PivotalPartnership

In 2019, partnered to leverage its enterprise platform for application development for catering to business need of

microservices based application modernization

CiE - IIOT ( Industrial

Internet-of-Things) COEInnovation

Launched in 2019 to develop innovative IIoT solutions that span across the technology stack for its customers in the industrial

manufacturing, automotive, healthcare and pharmaceutical, consumer products and goods, and utilities space

Change Healthcare Partnership

Wipro will globally provide Change with professional services for information technology including infrastructure, application

development and maintenance

Reltio Partnership

The alliance with Reltio enables the use of faster and cost effective master data management solutions, with big data

technologies to deliver pre-configured, industry-specific data models in an accelerated timeframe


EGR-2019-45-R-348598

®

Contents





⚫ Vendor profiles

⚫ Appendix


EGR-2019-45-R-348599

®

Term Definition

AI Artificial Intelligence is the simulation of human intelligence and decision-making capability by machines

API Application Programming Interface is a set of protocols, routines, functions, and/or commands that programmers use to develop software or

facilitate interaction between distinct systems

CoE A Center of Excellence refers to a team that provides support on a particular focus area

CRM Customer Relationship Management refers to practices and technologies firms employ to manage customer interactions and analyze customer data

EHR Electronic health record

ERP Enterprise Recourse Planning refers to practices and technologies firms employ to integrate back-office business processes and facilitate the flow

of information within an organization

IP Intellectual Property includes intangible creations of the human intellect, and primarily encompasses copyrights, patents, and trademarks

ITS Information Technology Services is the transfer of ownership of some or all information technology processes or functions to a service provider.

This could include administrative, delivery, or management-related processes or functions

R&D The research and development processes involved in creating a drug

Robotic process

automation (RPA)

It refers to a type of automation, which interacts with a computer-centric process through the User Interface (UI) / user objects of the software

application supporting that process. It is typically deployed on virtual machines and can enable end-to-end process automation without the need for

human triggers

Service provider A company/entity that supplies outsourcing services to another company/entity

Glossary of key terms used in this report


EGR-2019-45-R-3485100

®

Healthcare Payer Annual Report 2018: Payers Look at Digital to Reinvent in a Turbulent Healthcare Market March 2018

Healthcare Payer Digital Services PEAK Matrix™ Assessment and Service Provider Landscape – 2019 December 2018

Healthcare Provider Digital IT Services – Service Provider Landscape with Services PEAK Matrix™ Assessment 2018 December 2018

Healthcare Payer Payment Integrity Solutions PEAK Matrix™ Assessment 2020 October 2019

Healthcare IT Security Services PEAK Matrix™ Assessment with Service Provider Landscape 2020 December 2019

Healthcare Payer Digital Service PEAK Matrix™ Assessment with Service Provider Landscape 2020 December 2019

Research calendar – Healthcare IT Services (ITS)

PlannedPublished Current release

Note: For a list of all our published HLS ITS reports, please refer to our website page

Dr. Robot Will See You Now: Unpacking the State of Artificial Intelligence in Healthcare – 2019 November 2018

Guidebook for Blockchain Adoption in Healthcare and Life Sciences: A Compilation of Insights from 40+ Blockchain Projects March 2019

Healthcare Report Card 2018 – A Guidebook of Key Trends and Service Provider Performance March 2019

Big Tech in Healthcare: What it Means for CIOs? November 2019

Flagship Healthcare ITS reports Release date

Thematic Healthcare ITS reports

https://www2.everestgrp.com/reports?Cat0=1161


EGR-2019-45-R-3485101

®

Additional HLS IT services research references

The following documents are recommended for additional insights on the topic covered in this report. The recommended documents either provide

additional details or complementary content that may be of interest

1. Healthcare IT Security Services PEAK Matrix™ Assessment 2020 (EGR-2019-45-R-3456); December 2019. Healthcare challenges, such as changing

business and care delivery models to support patient-centricity are leading to increased investments in data and technology by enterprises. The healthcare

industry has been slow to respond to cyber threats and has lagged behind other industries when it comes to IT security investments, making healthcare a

lucrative target for hackers. As a result, the past few years have seen some of the biggest attacks on healthcare enterprises resulting in theft of millions of

patient records

2. BigTechs in Healthcare: Reimagining the Ecosystem (EGR-2019-45-R-3418); November 2019. BigTechs such as Amazon, Apple, Facebook, and

Google have a track record of disrupting industries such as retail and telecommunications. The tech giants are now eyeing healthcare – with many having

already made significant investments in the industry. This interest is driven by factors such as increasing healthcare spend, demand for data analytics, and

rising member/patient expectations. The maximum disruption has been created in areas largely outside the traditional scope (payer, provider, PBM, etc.) of

the healthcare industry

3. Healthcare Payer Payment Integrity Solutions PEAK Matrix™ Assessment 2020 (EGR-2019-32-R-3371); October 2019. Claims processing is

becoming ever more complex for payers, given issues such as the need to transform healthcare plans’ business models to accommodate new markets and

new lines of business, increasing inflow of members, and increasing regulatory mandates. Payment integrity is a potential help – it can reduce rising

healthcare waste and fraud to ensure that the medical claims are paid correctly and free of wasteful and abusive practices

Website: www.everestgrp.com | Phone: +1-214-451-3000 | Email: [email protected]

For more information on this and other research published by Everest Group, please contact us:

Abhishek Singh, Vice President: [email protected]

Chunky Satija, Practice Director: [email protected]

Nitish Mittal, Practice Director: [email protected]

Kanika Gupta, Senior Analyst: [email protected]

Priya Sahni, Senior Analyst: [email protected]

Abdul Rahman Shaikh, Analyst: [email protected]

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Everest Group - Healthcare Payer Digital Services PEAK Matrix ...€¦ · This, in turn, is driving the need for research and market intelligence on demand and supply trends in healthcare