Specialist
Former VP at Optum Inc
Agenda
- Key trends and developments in the healthcare payments solutions market
- Increasing payment accuracy solutions through overpayment recovery and prepayment accuracy
- Competitive landscape deep dive, including main strengths and weaknesses of Optum (NYSE: UNH), Cotiviti, Zelis and MultiPlan (NYSE: MPLN)
- Past M&A overview and synergistic analysis, including prospective future consolidation trends
- 3-5-year market growth outlook and key business risks
Questions
1.
What major trends and developments have you been following in the healthcare payments software market over the past 12 months or so?
2.
What’s your assessment of the remaining market opportunity within Medicare and Medicaid contracts for post-payment recovery for government entities looking to escrow future payments? How do those contracts work, and what are the major differences from prepayment arrangements with payers?
3.
What are the main criteria for who wins and loses on government contracts, and how does the typical stickiness differ on those relationships?
4.
Where do you see further room for automation within claim auditing, and what kind of efficiency potential could be realised there?
5.
In a previous Forum Interview [see Zelis – Q4 2022 Company Update & Expansion Strategy – 28 November 2022], a specialist said that around 20% of payer claims volumes don’t have a primary editor. What are the keys to going after this untapped market opportunity? Do you agree with this metric?
6.
How are players looking to supplant the leading positions of Optum and ClaimsXten in claims editing? How resilient are their competitive moats?
7.
What could be the potential synergies from combining ClaimsXten and MultiPlan, for example? Is this something that the private investor ownership of ClaimsXten would consider?
8.
Where do you see low-hanging fruit to capture further savings for payer clients across auditing, editing, integrity, optimisation, etc?
9.
I appreciate you weren’t quite as involved with some of the NSA [No Surprises Act] dynamics, but how are the remainder of out-of-network claims being adjudicated? What are the core financial differences between negotiations from a Medicare multiple standpoint, reference-based pricing, etc?
10.
How are major vendors such as MultiPlan, Zelis, Optum and Cotiviti viewed in the marketplace in terms of analytics capabilities, cost savings and other support services? How would you describe their reputations or relative strength of customer relationships?
11.
How do you assess the relative positioning and disruptive potential of smaller vendors such as Elap, AMPS, Performant Healthcare, OccuNet and others? What payment dollars are they going after, and who do you see as better-situated to encroach on incumbents’ market share?
12.
What are the main considerations when cross-selling payment integrity, optimisation and out-of-network solutions to existing customers? What kind of increased revenues could be realised here?
13.
We’ve discussed M&A trends to some extent, but how might players continue to deploy capital across strategic M&A, organic product investment or otherwise over the next 12-18 months or so?
14.
Where do you see some of the more attractive growth opportunities in this market, whether service-wise or secular trends for vendors to capitalise on?
15.
Is anything else important to highlight around the healthcare payments software market?
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