In Part 1 of this two-part series, we examined the top five technology areas receiving increased investment from healthcare payers in 2025, according to the 2025 Gartner CIO and Technology Executive Survey. Now, we turn to the next set of high-priority investments aimed at further optimizing payer operations.
Based on Gartner’s survey of healthcare CIOs, Part 2 will cover the following key areas of increasing investment:
- Data science and machine learning platforms (31%)
- Analytics tools for payer use cases (27%)
- Provider data or network management applications (23%)
- Data management and enrichment tools (20%)
- Payment integrity tools (18%)
- Value-based payment and analytics tools (18%)
Each area presents significant opportunities for payers to enhance decision-making, improve data quality, and drive cost savings. Let’s explore these investments and their impact on the healthcare payer industry.
Data Science and Machine Learning (ML) Platforms
Data science and machine learning platforms are becoming a strategic pillar for healthcare payers. These technologies enable payers to build predictive models, gain deeper insights into patient populations, and automate decision-making processes, improving efficiency across multiple operational areas.
Machine learning is particularly valuable for predicting high-risk patients, optimizing care pathways, and detecting fraud. According to Accenture, AI and ML in healthcare could save the U.S. economy $150 billion annually by 2026.1 These platforms enable payers to enhance the accuracy of predictive analytics, improving outcomes while driving down operational costs.
Why This Matters: Payers that leverage data science and machine learning gain a competitive edge through more accurate forecasting, better decision-making, and automation of complex processes—leading to both cost savings and improved patient outcomes.
Analytics Tools for Payer Use Cases
Analytics Advanced analytics tools are becoming increasingly vital for healthcare payers seeking to optimize operations, reduce costs, and improve patient outcomes. These tools allow payers to analyze claims data, perform member segmentation, and conduct financial forecasting, all critical for managing risk and controlling expenditures.
By leveraging real-time analytics, payers can gain insights into trends in member behavior, optimize provider networks, and monitor key performance
indicators to drive organizational performance. According to Clarify Health, business intelligence (BI) tools are key for making data actionable, allowing healthcare organizations to strategically manage revenue cycle operations, reduce claim denials, and enhance patient care.2 This integration of analytics supports better decision-making and ensures payers can stay competitive in a rapidly changing environment.
Why This Matters: Analytics tools equip payers with the actionable insights necessary to streamline operations, identify cost-saving opportunities, and make data-driven decisions that directly impact their bottom line. These tools are essential for navigating the complexities of modern healthcare.
Provider Data or Network Management Applications
Managing provider networks efficiently remains a major challenge for healthcare payers, largely due to complex and often fragmented data management processes. Many payers rely heavily on manual work to maintain accurate, up-to-date provider directories, manage contracts, and ensure compliance with regulatory standards. This manual approach can lead to data inconsistencies and delays, impacting overall network performance.
Improvements in provider data management streamline these processes and enable payers to feed accurate provider data directly into their payment integrity solutions. This integration helps prevent errors and reduces inaccurate payments, aligning with payer goals to enhance data integrity and cost control. By investing in more sophisticated network management applications, payers can improve data accuracy and simplify workflows, building a foundation for more effective provider collaboration and operational efficiency.
Why This Matters: Streamlined provider data management is critical for healthcare payers to reduce manual work and improve data accuracy. These applications not only support regulatory compliance and provider collaboration but also enhance payment integrity by feeding clean, accurate data into downstream systems, ensuring more precise claims processing and cost savings.
Data Management and Enrichment Tools
Data is at the core of payer operations, but ensuring data quality remains a challenge. Data management and enrichment tools are essential for cleaning and organizing payer data to ensure accuracy.
These tools enhance data quality by reducing duplicates, improving interoperability, and enriching member records. Poor data quality remains a widespread issue across healthcare and technology sectors, leading to inefficiencies that stem from data errors, duplicates, and incomplete records. These data challenges drive up operational costs and hinder effective decision-making. For healthcare payers, verifying data accuracy and streamlining data management is critical to reducing fraud, improving claims processing, and enhancing overall operational efficiency.
Why This Matters: High-quality data is the foundation of successful payer strategies. By investing in data management and enrichment tools, payers can increase operational efficiency, reduce errors, and enable better decision-making that drives financial performance.
Payment Integrity Tools
As healthcare payers seek to reduce fraud, waste, and abuse in claims processing, payment integrity tools have become essential. These tools utilize advanced anomaly detection and machine learning algorithms to identify unusual patterns in claims data, allowing payers to prevent improper payments before they occur. Recent advancements in provider coding practices and revenue cycle management (RCM) have led to higher claim severity, adding to the complexity and making accurate detection even more critical.
The National Health Care Anti-Fraud Association (NHCAA) estimates that healthcare fraud costs the U.S. system more than $68 billion annually, underscoring the importance of robust payment integrity solutions.3
To ensure consistency and accuracy in payment integrity, payers are increasingly adopting an enterprise-wide approach, aligning processes and thresholds across different teams. By standardizing these elements, payers can establish a cohesive strategy that enhances fraud detection, improves claim accuracy, and mitigates financial losses.
Why This Matters: An enterprise approach to payment integrity, combined with advanced anomaly detection capabilities, empowers healthcare payers to address the complexities of today’s claims environment. Standardizing payment integrity processes across teams not only reduces financial losses due to fraud but also ensures more accurate and efficient claims processing, providing a stronger, organization-wide defense against fraud, waste, and abuse.
Value-Based Payment and Analytics Tools
As value-based care (VBC) models gain traction, healthcare payers are increasingly investing in value-based payment (VBP) and analytics tools. These tools are designed to align payers and providers around quality metrics, ensuring reimbursements are tied to patient outcomes rather than service volume. However, realizing the full ROI from VBC tools requires prioritizing strong, collaborative relationships between payers and providers. Many providers lack the tools needed to gain actionable insights, making it essential for payers to support these partnerships and bridge technology gaps to foster a people-centered approach.
With relationships as the foundation, streamlined processes come next, providing both payers and providers with workflows that make it easier to monitor performance and manage value-based contracts. Finally, robust data completes the framework, enabling real-time insights and accurate evaluations that support continuous improvement and financial success in VBC models.
Why This Matters: To achieve meaningful ROI from VBC tools, healthcare payers must invest in the pillars of People, Process, and Data. By building strong provider relationships, establishing effective workflows, and leveraging accurate data, payers can support their provider partners in delivering better outcomes, thereby driving success in a value-based healthcare environment.
The Path Forward for Healthcare Payers in 2025
As healthcare payers continue to adapt to an evolving landscape, their investment priorities reflect a growing emphasis on data-driven decision-making, payment integrity, and value-based care. Technologies like machine learning platforms, provider network management applications, and payment integrity tools are becoming essential to building more efficient, cost-effective operations while improving care outcomes.
By strategically investing in these areas, payers not only ensure compliance with regulatory demands but also position themselves competitively in an increasingly complex healthcare market. As healthcare continues to evolve, staying ahead of these technological advancements will be crucial for payers aiming to scale efficiently and deliver better outcomes for members.
Ultimately, the key to success lies in leveraging these technologies to drive operational efficiency while maintaining a strong focus on improving patient care. This balanced approach will enable healthcare payers to thrive amid the challenges and opportunities that 2025 and beyond will present.
With HealthAxis’ forward-thinking technology and expert team by your side, you can confidently navigate this evolving landscape. Schedule a discovery call today to explore how we can help you achieve success in 2025 and beyond.
Author:
Eric Strikowski
Chief Innovation Officer
Sources:
- AI: Healthcare’s New Nervous System, Accenture
- Why Healthcare Organizations Need Business Intelligence Tools Today, Clarify
- FWA Is Increasing. Healthcare Costs Are Spiraling, 4L Data Intelligence
