AI, Value-Based Contracting, Digital Health Integration, and CMS Readiness Lead Consulting Priorities in Year Ahead, 18 Advisors to Engage Now
LAS VEGAS, NV / ACCESS Newswire / June 13, 2025 / Black Book Research today released its latest client satisfaction rankings of the top-performing Payer IT consulting and advisory firms, ahead of the AHIP 2025 Conference in Las Vegas. Based on input from 1,247 health plan executives across 240 managed care organizations collected in Q3 2024 -Q2 2025, the survey reflects the evolving technology priorities reshaping the payer sector.
The independent study evaluated consulting firms across key performance indicators (KPIs) such as strategic innovation, regulatory expertise, execution excellence, ROI, and overall satisfaction. Black Book's methodology emphasizes qualitative client insights and longitudinal satisfaction tracking, uniquely capturing the true value consultants deliver to payer organizations. To achieve statistically reliable results with a ±3% margin of error at a 95% confidence level, Black Book Research determined an optimal survey sample size of 890 senior-level executives from a population of 5,330 health plan IT, administrative, and finance leaders nationwide.
Top 5 Areas Driving Payer IT Consulting Engagements in 2025-2026
I. Regulatory Compliance and CMS Audit Readiness: As Medicare Advantage audits intensify and enforcement of federal rules like the No Surprises Act and Transparency in Coverage expands, consultants are essential in guiding health plans through complex compliance and documentation strategies. 86% of all MA plans have engaged or are in the process of contracting a relationship with an advisory firm by Q4.
The Top Payer-Rated Firms in Regulatory Compliance & CMS Audit Readiness for Health Plans
1. PwC (PricewaterhouseCoopers) Health Industries Advisory: Expert in Medicare Advantage audit preparation, risk adjustment validation, and enterprise compliance strategy. Their end-to-end advisory spans from readiness assessments to corrective action planning and CMS submission protocols. National health plans report significant audit penalty reduction and improved documentation accuracy under PwC's guidance.
2. Inovalon, Consulting and Analytics Division: Combines SaaS-based analytics with consulting to support Medicare Advantage plans in audit readiness, encounter data management, and compliance tracking. Delivers measurable improvements in CMS compliance metrics and RADV defensibility, particularly for mid-to-large MA plans. (AHIP 25 Exhibitor Booth 1207)
3. Deloitte Consulting - Government & Public Services, Health Plan Compliance: Specializes in guiding payer organizations through CMS audit cycles, implementing compliance technology, and building risk governance programs.Widely trusted for delivering integrated solutions that prepare organizations for RADV audits and regulatory shifts.
4. Milliman: Offers actuarial and IT-focused compliance consulting, particularly around risk adjustment modeling, coding accuracy, and compliance analytics. Supports payers in building statistically defensible models for CMS scrutiny and avoiding audit-related financial exposure. (AHIP 25 Exhibitor Booth 1627)
II. Pricing Transparency and Consumer Engagement: Payers are heavily investing in platforms and strategies designed to enhance transparency, consumer experience, and accurate real-time cost estimations.
Top Payer-Rated Firms in Pricing Transparency & Consumer Engagement for Health Plans:
1. HealthEdge (Now part of Altruista / GuidingCare by WellSky): Provides modern payer core administration systems with embedded transparency and cost estimation tools that enhance consumer engagement and price clarity.HealthEdge enables real-time benefit and pricing data visibility at the point of care and member decision-making. (AHIP 25 Exhibitor Booth 1000)
2. Softheon: Specializes in ACA, individual, and small-group plan enrollment platforms that include integrated pricing calculators, subsidy estimators, and consumer shopping tools. Trusted by Medicaid MCOs and exchange plans to power compliant, consumer-friendly digital experiences.
3. AVIA: Focused on digital transformation roadmapping, AVIA helps payer organizations select and implement consumer engagement and pricing solutions tailored to their member populations. AVIA's innovation network drives actionable transparency benchmarks for regional and community-based health plans.
4. PwC Health Industries Advisory: Offers strategic consulting and implementation services focused on consumer-facing digital transformation, including compliant pricing tools, plan comparison modules, and member journey mapping. Payer clients credit PwC with significantly improving member experience scores and digital transparency capabilities.
III. AI and Advanced Analytics Enablement: Advisors are increasingly deployed to lead initiatives around AI-driven predictive modeling, automated claims adjudication, and fraud detection - areas showing measurable ROI and operational impact.
Top Firms in AI & Advanced Analytics Enablement for Payers:
1. SAS Institute - Health & Life Sciences: Longstanding leader in payer-specific advanced analytics, including fraud, waste, and abuse detection, cost containment, and actuarial forecasting. SAS solutions are widely adopted by state Medicaid and large commercial insurers for mission-critical AI model deployment. (AHIP 25 Exhibitor Booth 1400)
2. Sutherland Healthcare: Specializes in AI-enabled RPA (robotic process automation) for payers, including claims processing, eligibility checks, and payment integrity analytics. Clients report high returns on investment, with measurable gains in efficiency and reduced claims leakage. (AHIP 25 Exhibitor Booth 1500)
2. Optum Advisory Services: Deep payer-domain expertise in applying AI to claims adjudication, fraud detection, and predictive risk scoring. Optum combines consulting with technology deployment for enterprise-scale transformation. Health plans working with Optum report significant improvements in claims processing speed, payment integrity, and clinical outcomes forecasting. (AHIP 25 Exhibitor Booth 1427)
3. CitiusTech: Provides payer analytics and AI-driven population health platforms, with expertise in data lake architecture, NLP, and fraud detection. Known for accelerating payer adoption of FHIR and data science capabilities to support predictive member analytics and provider network optimization. (AHIP 25 Exhibitor Booth 1501)
4. Veradigm: Offers integrated analytics platforms for payers with strong capabilities in predictive risk adjustment, pharmacy claims analytics, and population segmentation.: Clients use Veradigm tools to streamline data science workflows and improve outcomes-based contract execution.
IV. Digital Health Ecosystem Integration:
Consulting firms are guiding health plans in aligning telehealth platforms, virtual care infrastructure, and digital health apps with enterprise workflows to enhance member services and network efficiency.
Top Payer-Rated Firms in Digital Health Ecosystem Integration for Payers:
1. Cognizant: Known for its strong payer-focused digital engineering capabilities, Cognizant enables seamless integration of virtual care platforms, remote monitoring apps, and digital front-door solutions into payer ecosystems. Health plans leveraging Cognizant report improved care continuity, higher digital adoption rates, and streamlined virtual care workflows.
2. PwC: Offers strategic planning and tech enablement services focused on integrating digital health tools into payer benefit structures, member portals, and care management programs. PwC supports clients in transforming siloed digital solutions into unified ecosystems that drive measurable improvements in member engagement and provider collaboration.
3. ZS Associates: Applies a data-driven lens to digital health integration, helping payers design and scale virtual-first care programs and align vendor partnerships with business KPIs. ZS clients report stronger ROI from virtual care investments and improved targeting of digital interventions based on member segmentation analytics.
4. Huron Consulting Group: Provides cross-functional integration advisory, enabling health plans to seamlessly harmonize telehealth and virtual care workflows with existing payer-provider systems and operational processes. Huron's clients report reduced technology fragmentation, improved care coordination, and strengthened provider network efficiency.
V. Value-Based Reimbursement Optimization:
With CMS continuing its aggressive push toward alternative payment models (APMs), risk-based contracting, and performance-based reimbursement, health plans are increasingly relying on specialized consultants to optimize value-based care strategies, enhance revenue accuracy, and manage risk-adjusted payment methodologies. According to Black Book surveys, 93% of health plans are actively seeking expert guidance to meet or exceed CMS benchmarks and manage risk contracts effectively.
Top Firms in Value-Based Reimbursement Optimization for Health Plans:
1. CareAllies (a Cigna Company): Provides integrated consulting focused on Medicare Advantage and commercial risk-based programs, emphasizing provider engagement, care coordination, and outcomes-driven reimbursement. CareAllies has enabled payers and provider groups to successfully transition into and optimize value-based care contracts, resulting in improved quality measures and financial outcomes.
2. Premier, Inc.: Delivers deep expertise in aligning clinical operations and analytics around value-based care, supporting plans in improving performance metrics, reducing unwarranted variation, and maximizing shared savings opportunities. Health plans leveraging Premier's consulting have reported significant enhancements in clinical outcomes, payment predictability, and CMS performance alignment.
3. Lumeris: A recognized leader in operationalizing value-based care models and risk-sharing arrangements, Lumeris provides comprehensive advisory services including risk adjustment analytics, quality program design, and accountable care strategies. Lumeris consistently demonstrates measurable results, helping health plans achieve significant improvements in STAR ratings, reduced medical spend, and enhanced CMS compliance.
4. Milliman: Offers advanced actuarial and financial modeling services focused on value-based reimbursement, including accurate risk adjustment, cost benchmarking, and alternative payment model evaluations. Milliman has helped numerous health plans achieve financial accuracy and improved margins in Medicare Advantage and APM initiatives. (AHIP 25 Exhibitor Booth 1627)
"Consulting partners are playing a mission-critical role in helping payers manage digital disruption, regulatory flux, and rising consumer demands," said Doug Brown, Founder of Black Book Research. "Our latest pre-AHIP 25 survey reveals which firms are delivering measurable results and real strategic value to health plans across these key domains."
2026 Outlook: AI-Driven Claims and Analytics Take Center Stage
Health plan executives forecast that AI-driven analytics, claims automation, and smart workflow redesign will dominate payer consulting engagements into 2026. As financial pressures grow and CMS incentives evolve, payer organizations are prioritizing vendor-agnostic guidance in selecting and implementing next-generation technologies that deliver efficiency, accuracy, and actionable insights.
For the full 2025 rankings, to license consulting firm scorecards, and proprietary, customized data insights, please contact the Black Book Research Press Office at research@blackbookmarketresearch.com.
About Black Book Research:
Black Book Research is a leading healthcare IT market research and public opinion polling firm, known for its crowd-sourced, unbiased satisfaction studies. Since 2009, Black Book has conducted over 3.3 million polling interactions to provide accurate, stakeholder-driven insights into software, services, consulting, and outsourcing solutions across healthcare and nearly 1 million from managed care, health plan and payer organizations alone.
Press Contact:
Black Book Research Press Office
research@blackbookmarketresearch.com
800-863-7590
SOURCE: Black Book Research
View the original press release on ACCESS Newswire
