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Claims Management 2023
Functionality Top of Mind for Organizations Making Purchase Decisions (A Decision Insights Report)
Author
Dustin Cragun
Author
Ciera Walker
Author
Jaren Day
The financial well-being of healthcare organizations is critical, especially given the macroeconomic pressures they face today. Many are looking at claims management and clearinghouse technology to maximize cash collections and reduce administrative burdens. To better understand what factors are influencing purchase decisions and which vendors are seen as capable of driving success, this report examines 24 recent purchase decisions validated by KLAS between February 2020 and November 2022. For additional context, satisfaction data from current customers is also included. It should be noted that the decisions in this report are not a comprehensive representation of all claims management purchase decisions made in the last several years.
Experian Health and Quadax Frequently Considered Thanks to Well-Rounded Functionality
Experian Health—a well-known vendor in the claims management market—is both the most considered and most selected vendor in this sample, and they are considered across all respondent organization sizes. Organizations often choose them for the product’s broad functionalities, like the customizable work queue and the reporting and analytics. Other reasons for selection include the affordable cost and the solution’s integration capabilities with EMRs and additional systems. Current customers of Experian Health are satisfied with the solution’s ease of use and the detailed reporting, which helps customers proactively address denials. Quadax, the 2022 Best in KLAS winner for claims management, is often considered for the product’s end-user capabilities, including claim edits, coordination of benefits, and secondary claim management. Current customers report the vendor is an exceptional partner—representatives come on-site regularly, and the support team quickly resolves issues. Some customers say the solution is easy to use, and they appreciate the functionality for editing claims and attaching records to them.
Cost a Major Driver for Customers Replacing Change Healthcare and FinThrive
Change Healthcare—who completed a merger with Optum in late 2022 (after data collection for this report)—is most often up for replacement, particularly among customers with 200 or fewer beds. Those who are replacing most commonly report frustrations with the increasing cost; other concerns include slow support and the vendor overpromising and underdelivering product improvements. Leaving customers are moving to a variety of vendors, most often SSI Group and Experian Health. Still, Change Healthcare is the third most-considered vendor, with organizations pointing to the vendor’s large market presence and an existing relationship from using the vendor’s other products. Current customers say the reporting capabilities save time and provide in-depth information. However, customer satisfaction is the lowest of any vendor in the report; respondents cite nickel-and-diming and recent turnover among support staff and account managers, resulting in declining customer support and delayed resolutions. Customers who have a consistent relationship with their account manager often report a better experience. Regarding the Optum merger, customer feedback is mixed, with some worrying the merger will distract Change Healthcare from focusing on customers.
All interviewed customers replacing FinThrive also cite cost as the main reason for leaving. Further, both unsatisfied and satisfied customer respondents believe the vendor nickel-and-dimes for additional services not included in the original contract. Customers appreciate the tool’s ease of use, which helps them quickly achieve desired outcomes. Additionally, some highlight FinThrive’s comprehensive portfolio of revenue cycle offerings.
SSI Group’s Integration Capabilities Appeal to Organizations; Waystar and Olive Chosen for Pricing and Functionality
SSI Group is equally selected and replaced in this data sample. Organizations consider SSI Group for the product’s functionality and integration capabilities, and many who selected are excited about how the solution advances EMR integration and clearinghouse reporting. The organizations who replaced SSI Group said the vendor wasn’t developing the product to meet their specific functionality requests. Current customers highlight the vendor’s partnership and support, though some would like more proactive communication regarding outages and downtime. Two organizations chose Waystar because of the pricing and automation features. Multiple current customers say the solution’s robust features—like the custom rules and reporting—are major drivers of satisfaction. They also appreciate the vendor’s end-to-end revenue cycle suite that complements the claims management offering. Olive’s solution (acquired in 2021 from Healthcare IP) was also selected by two organizations because of competitive pricing and functionality. Current customers are highly satisfied with the product, mentioning a responsive support team and a strong partnership with the vendor, who assists with payer enrollment.
Claims Management Purchasing Insights
A Note about Availity
Though Availity’s performance has been measured by KLAS for several years, no purchase decisions involving Availity were validated for this report. Current customers are mostly satisfied with the solution and say the training makes it easy to submit claims. Most customer respondents report satisfaction with the support; the few that are unsatisfied would like to escalate concerns more easily and resolve outstanding issues more quickly.
Voice of the Customer
Vendors ordered alphabetically
“I have worked with a lot of different clearinghouses, and Availity’s clearinghouse system is more intuitive than most; it is more forgiving. There are errors that other clearinghouses would fail a whole batch for, but Availity’s system is able to pick out the claim with the error or sometimes even fix the error. I have even had batches that have failed at first, and the system has figured out what was wrong and repaired the issue, so I found that to be quite impressive. A different product that I used in the past would reject a whole batch of claims if there was an extra space in a field.” —Analyst, current customer
“Maybe our previous vendor spoiled us. That vendor held our hand. Their personal representative was regularly on-site, and we had regular meetings with them to discuss any concerns. They gave us the limousine version of their clearinghouse, whereas Availity’s clearinghouse is more of a Toyota. There is nothing wrong with Availity, but their level of customer service is not where it should be.” —Manager, current customer
“My billers like Change Healthcare and their edits because they will direct us right to the LCDs for Medicare and let us know why an edit may not be going through. The edits are great, and the product is a very user-friendly program once someone gets familiar with it. There is a lot of functionality, and I can’t think of any needs that the product doesn’t meet.” —Manager, current customer
“Every little add-on product costs a certain amount of money. We opted for the basic model and came to find out that we would have to pay quite a substantial cost to get the other features. I don’t know how the cost compares to that of other products, but it just seems like Change Healthcare’s system is expensive.” —Analyst, current customer
“We like the fast response we get with the automation in ClaimSource, and we are excited to take advantage of some of the new functionalities that the vendor is pushing out. ClaimSource CRD files will now be able to integrate with our EMR, and we will be able to revalidate claims within minutes. We have a very high clean claims rate with the tool, and the vendor keeps all their promises. ClaimSource is a great tool, and things are going well.” —Manager, current customer
“The vendor is constantly a work in progress. One opportunity for improvement is their turnaround time for support tickets. In general, we put in a lot of work and time to get the support people to respond. That situation is getting better, but the support is a work in progress and that is annoying. We have to escalate issues, and we have to set up regular meetings to address any issues and make sure we are satisfied. The vendor’s management is great, but I have to get my management involved with their management to make sure that our needs are being met. That is ridiculous. Considering the amount of money that we are paying, we should get great support. The support issue is big.” —Analyst, current customer
“The claims management system has a really good workflow in it. The system also has really good reporting; there is a report writer within the system, so we can literally pull out any data element we would like. FinThrive Revenue Systems has written a lot of customer edits for us, and the turnaround time to get a custom edit put in has been very good. The vendor is very timely with regulatory changes and making sure those are addressed and in the system. We can see EOBs and bills at the same time. There is a lot of automation there. I can’t think of anything I don’t like about the bill scrubber. The system is working really well for us, so overall I am happy with it.” —VP, current customer
“The system has had some add-on charges. Clients have to purchase certain analytics separately. Every time we add a location or facility to the solution, there are additional implementation charges.” —VP, current customer
“Olive is a bit better than we were originally told. The product is user friendly, and the vendor does a fairly good job of working with us on any major issues. Olive has been very good to us.” —Manager, current customer
“The dashboards in the product need to mean something and be improved so they are actually helpful. Right now, the dashboards don’t do anything. We can drill down in the reports, and that is a great feature, but we need to be able to group the rejections and categorize them instead of having individual rejections and denials separated.” —Business office director, current customer
“I really enjoy using Xpeditor. It is a great tool, and it is easy to use. The solution has really helped us to improve our A/R at multiple facilities. I have had good luck with using the tool. Its claims functionality is very user friendly, and it has a lot of supporting information and documentation on edits. Xpeditor cuts down on the research that our billers have to do internally. Our billers really appreciate that.” —Manager, current customer
“Some of Quadax’s secondary reporting could use some improvement. Quadax gives us the original total claims amount but doesn’t give us the amount that is actually going out for the secondary claim. Fixing that issue is the only suggestion that I have for Quadax. The same thing also happens with some of the rejection reports that come back with the remittances or the denials reports.” —VP, current customer
“The SSI Group does a few things better than anyone. They have pretty comprehensive editing suites, and they allow a stair-step approach to making edits. The system has provider-based edits, payer-based edits, and custom edits. With those types of edits, we can create a stair-step approach that really covers everything we need to get a clean claim.” —Director, current customer
“Overall, SSI Claims Management is fine and solid, but more innovation is needed, particularly in sourcing the claims edits that payers are now applying, such as UnitedHealthcare’s Smart Edits or the Blue Cross Blue Shield Association’s advanced claims editing content. As a provider, I desire to run my claims through those edits to correct them prior to transmission so that I don’t have to receive that feedback via 277s and other rejections. Furthermore, we need more from our enhanced status. I just need a single holistic solution for status rather than having three products: one for batch and non-real-time 277s, one for screen-scraping statuses from payer portals, and a real-time status module for actual EDI 276s or 277s via EMR integration.” —VP of business office, current customer
“Our experience with Waystar has been excellent from the very beginning. The vendor did a tremendous job with the go-live, and it was smooth. There was no uptick in A/R, and the cash flow was maintained and even improved. Our denials decreased, and our clean-claim rate went up and has been maintained ever since. I cannot speak highly enough about the vendor and their implementation expertise. I have done many implementations in my career, and Waystar’s implementation was by far the easiest.” —Director, current customer
“We chose Waystar’s system instead of the preferred clearinghouse that our EHR vendor recommended because we liked Waystar’s business model and how they presented themselves. However, as Waystar has grown and become a larger organization, we have seen fees associated with things that haven’t had fees in the past. We have also experienced a drop in customer service and responsiveness compared to the good response times we used to experience. Waystar’s support is not what it used to be.” —Analyst, current customer
About This Report
Data for this report comes from two sources: (1) KLAS Decision Insights data and (2) KLAS performance data.
KLAS Decision Insights Data
All references in this report to organizations’ purchasing motivations come from KLAS’ Decision Insights data. Since 2017, KLAS has been gathering information as to which vendors are being replaced, considered, and purchased and what factors drive these decisions. KLAS Decision Insights data does not represent a comprehensive census or win/loss market share study. Rather, it is intended to help organizations understand which vendors have market energy and why. The data set in this report comes from 24 organizations that are making or have recently made a claims management purchase decision validated by KLAS from February 2020 to November 2022.
KLAS Performance Data
Each year, KLAS interviews thousands of healthcare professionals about the IT solutions and services their organizations use. For this report, interviews were conducted over the last 12 months using KLAS’ standard quantitative evaluation for healthcare software, which is composed of 16 numeric ratings questions and 4 yes/no questions, all weighted equally. Combined, the ratings for these questions make up the overall performance score, which is measured on a 100-point scale. The questions are organized into six customer experience pillars—culture, loyalty, operations, product, relationship, and value.
Sample Sizes
Unless otherwise noted, sample sizes displayed throughout this report (e.g., n=16) represent the total number of unique customer organizations interviewed for a given vendor or solution. However, it should be noted that to allow for the representation of differing perspectives within any one customer organization, samples may include surveys from different individuals at the same organization. The table below shows the total number of unique organizations interviewed for each vendor or solution as well as the total number of individual respondents.
Some respondents choose not to answer particular questions, meaning the sample size for any given vendor or solution can change from question to question. When the number of unique organization responses for a particular question is less than 15, the score for that question is marked with an asterisk (*) or otherwise designated as “limited data.” If the sample size is less than 6, no score is shown. Note that when a vendor has a low number of reporting sites, the possibility exists for KLAS scores to change significantly as new surveys are collected.
Writer
Sarah Brown
Designer
Jessica Bonnett
Project Manager
Andrew Wright
This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2025 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.