Back to the patient in Texas who saw the skin doctor, from Industry Vertical 22, Digital health. The visit is over, but the clinic has not been paid. Most of its money comes not from the patient, but from the patient's insurance company. Getting that money is a process of its own:
Before the visit, check that the patient's insurance covers it. This is called checking eligibility.
For some treatments, get the insurer's approval in advance. This is called prior authorisation.
Turn the visit into standard medical codes: one code for the diagnosis, and one for each thing the doctor did. This is called medical coding.
Send the bill to the insurer. This bill is called a claim.
If the insurer refuses to pay, which is called a denial, follow it up and fight it.
Collect whatever the patient still owes.
The whole process is called the revenue cycle. It employs hundreds of thousands of people. A large share of them are in India, in the coding and billing centres of Chennai, Hyderabad, Bengaluru and Delhi.
The revenue cycle: check that the visit is covered, get prior authorisation where needed, code the visit, send the claim, follow up and fight any denial, and collect what the patient still owes; much of this work is done in coding and billing centres in Chennai, Hyderabad, Bengaluru and Delhi.
This Market Segment is about the software for the revenue cycle. The buyers are American hospitals and clinics, and the billing firms that do this work for them. Insurers are called payers, and hospitals and clinics are called providers.
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.
This Market Segment has two sub-segments:
The revenue-cycle platforms: the systems that providers and their billing firms run on.
The AI billing agents: newer companies that do the work itself.
The revenue-cycle platforms
Revenue cycle management platforms, eligibility and claims networks, clearinghouses, risk adjustment
Back to the skin doctor's claim from the start of this Market Segment. The clinic does not send it straight to the insurer. It usually goes through a clearinghouse: a company that checks each claim for errors, and passes it to the right insurer.
Inovalonwith engineers in Delhi and Hyderabad, has the most job postings in this Market Segment. It sells cloud software for the revenue cycles of both providers and payers: the eligibility check, the claim and the analysis. It is built on one of the largest collections of American claims data.
Availitywith engineers in Bengaluru, runs the network through which American providers check eligibility and send claims to many insurers, through one website and one API.
FinThrive and FinThrive Indiaits Indian company, both with engineers in Delhi, sell a revenue-cycle platform for hospitals that covers every step.
Smart Data Solutionswith engineers in Chennai, turns the paper claims and letters that still reach payers into digital data.
Reveleerreads medical records for risk adjustment and quality programmes. Medicare is the American government's health insurance for people over 65. Many Medicare plans are run by private insurers, and risk adjustment decides what each plan is paid: more for sicker patients.
Four companies covered mainly in other Market Segments bring the edges of the cycle:
GHXwith engineers in Hyderabad, is here for hospitals' purchasing of supplies, from the order to the payment. (More on it in Market Segment 30.1, Supply chain planning software, in Industry Vertical 30, Supply chain and logistics.)
Lyric and MDI NetworXwith engineers in Hyderabad and Pune, are here for claims editing and claims administration: the checks that decide what an insurer pays.
Care.fiwith engineers in Bengaluru, is here for the revenue cycle of Indian hospitals, and for lending money to them against their unpaid claims. (More on it in Market Segment 18.2, SME and business lending, in Industry Vertical 18, Lending and credit.)
Lyric and MDI NetworX are covered mainly in Market Segment 21.6, Health plan claims and care management (in Industry Vertical 21, Insurtech).
The AI billing agents
AI agents for coding, prior authorisation, eligibility, denials and payer calls
Back to the skin doctor's claim from the start of this Market Segment. Suppose the insurer denies it. Someone must find out why, fix the code, and send it again. Sometimes that means an hour on the phone with the insurer. The companies in this sub-segment sell AI agents that do this work, instead of software for people to do it with. All of them are small, and building in India.
CombineHealthwith engineers in Bengaluru, sells AI agents that code the visit, send the bill and fight the denial.
Arrowwith engineers in Mumbai, sells an AI workspace for the same billing work.
Risaautomates prior authorisation for cancer care.
Mantysautomates prior authorisation, eligibility checks and reconciliation, which means matching payments against claims.
Element5with engineers in Chennai, does the same for home-care providers, and for care after a hospital stay.
VoiceCare AIwith engineers in Bengaluru, sells a voice agent that calls insurers to check what a patient's plan covers and to chase unpaid claims. Billing staff used to spend hours on hold for these calls.
The revenue cycle run by agents.
The revenue cycle is paperwork, phone calls and rules. That is the work AI models do best, and it is done at enormous scale in India. The agents in this sub-segment, and the platforms adding the same, are automating the coding, the prior authorisation and the follow-up. The insurers are using their own AI models on the other side. More and more, the two sets of agents settle each claim between them. (More on the insurer's side in Market Segment 23.2, Health payer platforms and prior authorisation.)
One claim, two sets of agents: the claim goes from the clinic through a clearinghouse to the insurer, while billing agents on the provider side (CombineHealth, Arrow, VoiceCare AI) and the insurer's own AI models more and more often settle it between them.
So the skin doctor from the start of this Market Segment gets paid through a long chain of software. The eligibility is checked, the visit is coded, the claim is sent and checked, and a denial is fought, more and more often by an AI agent.