Health payer platforms and prior authorisation

The insurer's side, deciding whether to pay a claim and approving a treatment before it happens

Back to the skin doctor's claim from Market Segment 23.1, Revenue cycle management (RCM) software. It has left the clinic. Now it arrives at the patient's insurer, which must decide whether to pay it, and how much.

On the other side of every claim is the payer. In America, the payer is usually one of these:

a health plan, which is what Americans call a health insurance company or its policy
Medicaid, the health insurance for Americans on low incomes, run by each state
Medicare, the federal government's health insurance for people over 65

The payer's core system holds its members, the people it insures, and its contracts with providers. It checks each claim against them, decides, and pays. Around the core run two more jobs:

Prior authorisation

approving a treatment in advance.

Care management

helping members with serious or long illnesses get the right care.

Inside the payer: a claim from the clinic reaches the core system, which checks it against the members it insures and its contracts with providers, then decides what to pay; around the core run prior authorisation and care management.

This Market Segment is about the core system and these decisions. The buyers are health plans and state governments. The checks on claims and the care programmes sold to the same payers are covered in Market Segment 21.6, Health plan claims and care management (in Industry Vertical 21, Insurtech). This is a small Market Segment, with five companies.

Every company named here has posted software engineering jobs in India. Famous companies that don't actively hire software engineers in India are left out.

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Back to the skin doctor's claim from the start of this Market Segment, now inside the insurer.

HealthEdge

with engineers in Bengaluru and Hyderabad, has the most job postings in this Market Segment. It sells HealthRules Payer, the core claims system of many American health plans. Around it, it sells payment integrity, which catches claims that should not be paid, care management through its GuidingCare product, and member engagement. Its Bengaluru centre builds much of the product.

Gainwell Technologies

with engineers in Bengaluru, runs the Medicaid systems of American states. It handles the sign-ups, the claims and the payments of a programme that covers tens of millions of Americans on low incomes. (More on software for governments in Market Segment 44.1, Government software, in Industry Vertical 44, Govtech and nonprofits.)

Now suppose the skin doctor wants to prescribe an expensive treatment, which needs approval first. The next two companies decide such requests. The industry calls this utilisation management.

Cohere Health

with engineers in Hyderabad, sells prior authorisation decided with AI. The approval that a treatment will be paid for comes back in minutes, not days.

Autonomize AI

with engineers in Bengaluru, sells AI agents for the same decisions on treatments, claims and cover.

One company here works in India instead:

IHX

with engineers in Bengaluru, runs India's health-claims exchange, which passes claims between hospitals and insurers. It uses AI to process them. IHX belongs to the Perfios group. (More on Perfios in Market Segment 18.3, Credit bureaus, scoring and underwriting, in Industry Vertical 18, Lending and credit.)

The prior authorisation decided in minutes.

Prior authorisation is the most hated process in American healthcare. It delays care while the paperwork is reviewed. New federal rules now require payers to decide faster, and electronically. Cohere Health and Autonomize AI sell AI models that approve the clear cases at once, and send the rest to a clinician. The regulators have said that a model may approve a request, but only a clinician may decide to deny it.

Prior authorisation decided in minutes: an AI model reads the request for an expensive treatment and approves the clear cases at once, and sends everything else to a clinician, since a model may approve a request but only a clinician may deny it (Cohere Health, Autonomize AI).

So the skin doctor's claim from the start of this Market Segment ends up in the insurer's core system. There, software checks it against the patient's plan and the clinic's contract, and decides what to pay. And a request for an expensive treatment is more and more often approved by an AI model within minutes.

Who they hire

Who these companies hire, and for what, is on What health insurance and billing companies hire for.

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