Modernizing payer operations and platforms across the value chain — from claims and enrollment to cost of care and AI-enabled transformation.
Payer Modernization
Overview
Health plans face compounding pressure: rising medical costs, margin compression across every line of business, and members who expect consumer-grade experiences. PwC helps payers redesign both back-office operations and front-and-middle-office functions — spanning claims, enrollment, provider data, product configuration, utilization management, quality and Stars, care management, and cost of care, while embedding AI and automation to unlock capacity, improve outcomes, and reduce cost.
Market trends
Capabilities
- Claims & core admin modernization, adjudication redesign, and payment integrity
- Enterprise provider data management and directory modernization
- The future of product and benefit
- Cost of care management, medical economics, and affordability analytics
- Epic for Payers implementation and payer platform modernization
- Utilization management redesign and prior authorization modernization
- Stars performance improvement, quality management, and risk adjustment optimization
- Care management redesign, value-based care strategy, and network optimization
- Enrollment, billing, product configuration, and group setup modernization
Claims & core admin modernization, adjudication redesign, and payment integrity
Claims processing and payment integrity sit at the center of payer economics. We help health plans redesign claims operations through hybrid adjudication strategies, modular architecture, and automation — while strengthening payment integrity across prepay, post-pay, and coordination of benefits functions. Whether migrating claims platforms, transitioning to a BPaaS model, or embedding AI into workflows, we help reduce processing costs, improve accuracy, and position payers to recover value.
Enterprise provider data management and directory modernization
Inaccurate provider data creates downstream failures across claims, network adequacy, and member experience. We help payers build enterprise provider data strategies — from directory modernization and credentialing automation to AI-enabled data quality and vendor selection. Our work spans alliance partnerships and in-house transformation, helping health plans move from fragmented provider records to a single, trusted source of truth that supports regulatory compliance and operational efficiency.
The future of product and benefit
Payers are racing to win consumers and employers through personalized healthcare products, yet keeping pace with portfolio complexity is harder than ever. Success requires harnessing AI, analytics, and digital platforms to deliver tailored, accessible benefits—ensuring what's designed is what's implemented and what consumers can easily understand. AI-based tooling creates human-readable benefits mapped to clinical codes, booklets, and configured systems, driving fidelity across fragmented areas.
Cost of care management, medical economics, and affordability analytics
With medical cost trending higher and margins deteriorating across every line of business, payers need lever-level accountability for cost drivers. We help health plans identify, size, and act on affordability opportunities through medical economics analytics, value mining, and coordinated execution across utilization, network, and pharmacy levers. Our affordability lifecycle — from opportunity assessment through activation & impact measurement — connects analytics to measurable cost reduction.
Epic for Payers implementation and payer platform modernization
Epic’s payer solutions, including Tapestry and the Epic Payer Platform, can play a meaningful role in driving efficiencies, data interoperability benefits, and downstream clinical and quality outcomes. We bring Epic-certified team members and capabilities honed at some of the most complex US payer transformations in the market. Our approach reduces implementation risk, accelerates time-to-value, and positions health plans on platforms designed for interoperability and AI readiness.
Utilization management redesign and prior authorization modernization
Prior authorization has become one of the pressure points between plans, providers, regulators, and members. We help payers modernize utilization management through medical policy discipline, precision PA scope, digital intake, AI-enabled decisioning, and enterprise governance. Our goal is to move plans from 20% auto-approval rates toward 85–90%, reserving clinical reviewer capacity for complex cases while meeting CMS-0057 interoperability requirements and reducing provider friction.
Stars performance improvement, quality management, and risk adjustment optimization
CMS respecification changes and rising cut points are compressing Stars bonus eligibility, while risk adjustment audit scrutiny intensifies. We help health plans improve quality and Stars performance through integrated operating models, provider enablement, AI-enabled targeted engagement, and clinical data strategy. From HEDIS execution and HOS improvement to chart-level risk adjustment optimization, we connect quality operations to revenue protection and measurable member outcomes.
Care management redesign, value-based care strategy, and network optimization
Effective care management and value-based arrangements are levers for bending the cost curve while improving outcomes. We help payers redesign care management operating models, build population health analytics, optimize network design and provider performance, and structure value-based contracts that shift accountability from volume to outcomes. Our approach connects member-level analytics to intervention design, helping outreach targets the populations where cost trajectory can still be changed
Enrollment, billing, product configuration, and group setup modernization
Enrollment errors, billing leakage, and manual product configuration drain revenue and frustrate members. We help health plans modernize end-to-end enrollment and billing operations, streamline product and benefit configuration, and optimize renewals, case installation, and group setup processes. Our approach addresses commercial and government lines of business, reducing cycle times, improving first-pass accuracy, and building scalable operations that support growth
Insights
