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What is the national market share of clearinghouse vendors (non health plan) for eligibility verification of patient health insurance coverage via EDI 270/271/API transactions or manual lookup on a portal?
Hi there! Thanks for asking about the national market share for healthcare clearinghouse vendors, based on percentage of total eligibility verification requests. The short version is that after searching extensively through industry reports and databases, government sources, corporate websites, regulatory filings, and trusted media sites, I've determined that the information you requested is not publicly available for two reasons: 1. the only publicly available data on numbers of transactions does not provide breakdowns by vendor, and 2. industry leaders are usually reported based on market share of revenue. However, I was able to learn that there are approximately 5.572 billion non-health plan eligibility verification request transactions, and I was able to identify the top 11 leading vendors in this market. You will find a deep dive of my research and methodology below.
METHODOLOGY
After searching extensively, I have not been able to find any data to prove market share by number of eligibility verification requests for any vendors. First, I looked through industry research and reports, but without purchasing full reports, I was only able to find lists of leaders in the broader RCM and EDI markets based on revenue. I looked at regulatory filings and corporate websites for identified industry leaders, but was unable to find specific numbers of eligibility verification requests within these sources. Next, I searched for relevant databases, and while I found a nice data set from CAQH, none of the collected information revealed breakdowns of requests by vendor. Turning to reputable media sites, I was able to find an analysis of vendor choice by care sites, but further research revealed that the leading vendor in that analysis is a health-plan partner.
HELPFUL FINDINGS
While I could not find a direct answer to your question, I was able to gather some information about this topic that I think will be helpful for your project.
~Numbers of Eligibility/Benefits Verification Requests~
According to the 2016 CAQH Index, the estimated national volume of eligibility/benefits verification requests (ASC X12N 270/271) breaks down as follows:
Thus, we can calculate a total of 5.572 billion electronic and manual eligibility verification requests for non-health plan providers.
(1.220+3.832+0.221+0.299=5.572)
~Electronic vs. Manual Verifications~
Overall, for commercial medical health plans and providers, 76% of eligibility/benefits verification requests were fully electronic in 2015, while 21% were partially electronic, and 3% were fully manual. For commercial dental health plans and providers, 58% of these transactions were fully electronic, 30% were partially electronic, and 12% were fully manual.
CAQH goes on to note that while use of electronic transactions for both eligibility verification and claims status inquires is "increasing rapidly", manual transactions are not declining at the same rate, due to persistent use of telephone calls for these types of requests.
~Global EDI Market~
I was able to find three reports on the Global IDI market, each of which identified these key players:
Emdeon (U.S.)
Allscripts (U.S)
McKesson (U.S)
Optum Health (U.S.)
GE Healthcare (UK)
Siemens Healthcare (DE)
SSI Group (U.S.)
ZirMed (U.S.)
Passport Health (U.S.)
Capario (U.S.)
GE, Capario, SSI Group, Siemens, Passport Health, and Optum
Capario, GE, Siemens, Emdeon, Optum, McKesson, Passport Health, SSI Group, Allscripts, HealthFusion
Taking these together, we can surmise that the top nine leading EDI vendors in the U.S. are: Change Healthcare (Emdeon), Allscripts, McKesson, Optum Health, SSI Group, ZirMed, Passport Health, Capario, and HealthFusion.
~North American RCM Market~
The North American revenue cycle management (RCM) industry, which includes EDI vendors, is estimated to grow at a 12% CAGR from 2016 to 2021, reaching $40.44 billion by 2021.
According to MicroMarketMonitor's 2016 report, the leading companies in the North American RCM industry are:
Quest Diagnostics
Cerner Corporation
McKesson Corporation
Athenahealth, Inc.
Allscripts Healthcare Solutions, Inc.
eClinicalWorks, Inc.
CareCloud Corporation
The SSI Groups, Inc.
GE Healthcare (US)
Epic Systems
Siemens Healthcare (DE)
Kareo, Inc.
Note that this report indicated that two non-U.S.-based companies, GE and Siemens, are both leaders in the North American RCM market. Since these two companies were also identified as leaders in the global EDI market, we can be reasonably certain that they are also leaders in the U.S. EDI market, bringing our list of leading EDI vendors in the U.S. to 11 companies.
~Clearinghouse Vendor Selection~
Data from Definitive Healthcare shows that smaller hospitals are more likely to partner with clearinghouse vendors; care sites with less than 150 beds account for 66.6% of facilities which use clearinghouse.
This data shows that, across facilities of all sizes, 93% use NaviNet as their clearinghouse, with 2% choosing Quadex, 1% choosing RelayHealth (McKesson), 1% choosing SSI Group, 1% choosing ZirMed, 1% choosing Change/Emdeon, and 1% choosing other, unnamed vendors.
However, these market shares cannot be attributed to the full national landscape specified in your query, as NaviNet appears to be primarily a health plan partner.
POSSIBLE CONTINUED RESEARCH
In understanding what types of information are, and are not, publicly available around this topic, I can suggest a couple of other routes you might be interested in researching:
- Given that we'd identified the 11 leading companies in the U.S. EDI market, you could do a revenue comparison of these vendors.
-Given that we've identified both the total size of the North American RCM market and its leading companies, you could triangulate market share for each vendor by revenue.
CONCLUSION
To wrap it up, after searching extensively through industry reports and databases, government sources, corporate websites, regulatory filings, and trusted media sites, I've determined that the information you requested is not publicly available for two reasons: 1. the only publicly available data on numbers of transactions does not provide breakdowns by vendor, and 2. industry leaders are usually reported based on market share of revenue. However, I was able to learn that there are approximately 5.572 billion non-health plan eligibility verification request transactions, and that the top 11 leading vendors in this market are: Change Healthcare (Emdeon), Allscripts, McKesson, Optum Health, SSI Group, ZirMed, Passport Health, Capario, HealthFusion, GE Healthcare, and Siemens Healthcare.
If you’d like to continue research on any of the other topics I’ve outlined above, just let us know!
Thanks for using Wonder!