Comparing Medical Billing and Clearinghouse Software After the Change Healthcare Outage

On February 21, 2024, a ransomware attack against Change Healthcare, then the largest clearinghouse in the United States, took down claims processing for a large share of the country's medical practices and hospitals. The attack, attributed to the ALPHV/BlackCat group, entered through a Citrix portal that lacked multi-factor authentication. Change Healthcare processed an estimated 15 billion transactions a year before the attack and, according to the American Hospital Association, touched one in three patient records in the country. Full restoration of the clearinghouse took about nine months.

UnitedHealth Group, which owns Change Healthcare through its Optum subsidiary, paid roughly $22 million in ransom, spent more than $2 billion on remediation, and advanced more than $6 billion in interest-free funding to providers whose claims could not be submitted or paid during the outage. The breach that accompanied the attack exposed data on an estimated 190 million individuals, the largest healthcare data breach recorded in the United States. The American Hospital Association criticized the exclusivity clauses that had tied many practices to a single clearinghouse and argued that the industry had let one vendor reach a "utility"-level concentration of risk.

The outage is the reason this comparison exists in its current form. Before 2024, a practice choosing a clearinghouse or billing platform was mostly weighing cost, integration, and support quality. After 2024, redundancy and business continuity became part of that same evaluation, and several of the vendors covered below now compete partly on how they answer that question.

How bad the outage was, in the survey data

The American Medical Association surveyed more than 1,400 physicians and practice staff between March 26 and April 3, 2024, about five weeks after the attack began. Most respondents worked in practices with fewer than ten physicians. More than 77% were still experiencing disruptions a month in. Eighty percent had lost revenue from claims that went unpaid, and 78% had lost revenue from claims they were unable to submit at all. Fifty-five percent had used personal funds to cover practice expenses, and 31% had missed payroll.

The American Hospital Association ran a parallel survey of roughly 1,000 hospitals. Ninety-four percent reported a financial impact, and 74% reported a direct effect on patient care. A third of respondents said more than half of their revenue had been disrupted, and 60% said normalizing operations took anywhere from two weeks to three months. Kodiak Solutions, which tracks claims data across its client base, measured a $6.3 billion drop in submitted-claim value in just the first three weeks after the attack.

Why switching clearinghouses was harder than it sounds

Forty-eight percent of AMA survey respondents said they engaged an alternative clearinghouse during the outage. The survey's open-ended responses show why that was not a simple decision. One respondent estimated "approximately $10,000 just for the set-up of a 'back-up' clearinghouse." Another described a payer's clearinghouse change that added "an additional 2% charge on all claims... approximately $1,000,000." A third said their practice could not afford "to pay three times as much... to switch clearinghouses."

The slowest part of switching was not installing new software. At an AHIMA roundtable, Jason Considine of Experian Health explained that payers "weren't equipped to handle the massive influx of enrollment paperwork" once practices tried to move their claims elsewhere. Re-enrolling with each payer for electronic data interchange and electronic remittance advice, one payer at a time, was the actual bottleneck, not the clearinghouse switch itself.

Jackson Health System, a large public hospital system, projected losses of $30 million a month during the disruption. Afterward, the system moved to dual-vendor clearinghouse contracts and cross-trained staff, so that claims processing no longer depended on a single vendor or a single group of trained employees.

What changed afterward

Waystar and Availity absorbed a large share of the volume that moved off Change Healthcare. Waystar onboarded more than 30,000 providers through what it called an Accelerated Implementation Program, and Experity migrated all of its urgent-care clients to Waystar as a direct result of the outage. Availity launched a program called Availity Lifeline within 48 hours of the attack, offering free connectivity to displaced practices; the company reports it assisted more than 300,000 providers and 51 health systems, processed more than $5 billion in stalled claims, and built 115 new payer connections, at one point handling 12.7 million claims in a single day.

In January 2025, the American Hospital Association published a report recommending that clearinghouse redundancy become standard practice, warning against exclusivity clauses, and calling for vendors to demonstrate at least 30 days of downtime capability. The AHA, AHIMA, and the Medical Group Management Association have each said, in some form, that dependence on a single clearinghouse is now a solvency risk rather than an operational inconvenience. That consensus is the backdrop for the comparisons that follow.

Pure clearinghouses

Availity and Office Ally sit at this end of the market. Neither sells outsourced billing services; their business is moving and validating claims between practices and payers.

Availity operates a tiered structure. Essentials is free because participating payers sponsor the connection; Essentials Plus adds connectivity to non-sponsoring payers for a fee that is not published; Essentials Pro layers on revenue cycle tooling. Availity's customer base ranges from solo practices to large health systems. Across 152 GetApp reviews, Availity holds a 3.7 out of 5, with users praising the ability to check eligibility and claim status across multiple payers in one place, and complaining about support wait times and a confusing interface. Its response to the Change Healthcare outage, described above, is now the most visible part of its reputation.

Office Ally functions as something close to a pricing floor for this category. It charges no setup fee, no monthly fee, and no per-claim fee for claims sent to participating payers. A $44.95 monthly fee per Tax ID, plus a rendering NPI fee, applies only when more than half of a practice's monthly claim volume goes to non-participating payers. This fee structure is published directly by Office Ally rather than estimated by a third party.

A clearinghouse with RCM services layered on

TriZetto Provider Solutions, owned by Cognizant, sits close to the pure-clearinghouse category but adds revenue cycle services on top of claims connectivity. The company reports more than 11,000 payer connections, more than 650 direct EMR and practice management integrations, more than 4 billion transactions a year, more than 875,000 providers, and a 98% average payer acceptance rate. These are vendor-reported figures. Independent review data on TriZetto is sparse relative to its scale, which makes its reputation harder to verify than smaller, more heavily reviewed competitors.

Billing software, with and without a bundled clearinghouse

Waystar and Kareo/Tebra both sell software rather than outsourced billing labor, though only one of them documents an integrated clearinghouse.

Waystar bundles enterprise billing software with its own clearinghouse, covering claims scrubbing, eligibility checks, denial management, and patient payments. It skews toward mid-market and enterprise practices, and the company reports roughly 30,000 clients, more than 1 million providers, and more than $1.2 trillion in annual gross claims processed, though these are company-reported figures rather than independently audited ones. Pricing is quote-based and not published. Across 213 Software Advice reviews, Waystar holds a 4.4 out of 5, with reviewers citing automation and EHR integration as strengths and inconsistent support and a two-year claims archive limit as weaknesses. Waystar won 2025 Best in KLAS honors for Claims Management and Clearinghouse, and the company went public on the Nasdaq in June 2024 under the ticker WAY, raising roughly $967.5 million.

Kareo, now folded into Tebra under the branding "Kareo is now part of Tebra," sells billing, practice management, and EHR software in tiers ranging from a basic Billing Starter plan to a full practice suite, aimed at independent practices. Pricing is not published and requires a sales demo. Across 1,380 GetApp reviews, the largest review volume of any vendor in this comparison, Tebra holds a 3.9 out of 5. Reviewers cite ease of use and thorough billing features as strengths, and raise recurring complaints about slow support, unclear pricing, cancellation fees, and unexpected price increases.

Full outsourced revenue cycle management

athenahealth's athenaCollector and CareCloud's Concierge service sit at the outsourced end of the market, where the vendor's staff, not the practice's, handle billing and follow-up.

athenaCollector bundles outsourced RCM with a built-in clearinghouse and is the clearest large-vendor example of pure percentage-of-collections pricing in this comparison. Reported pricing runs 4% to 8% of monthly collections, inclusive of clearinghouse fees, on month-to-month contracts, according to business.com and corroborated by other pricing trackers; athenahealth itself does not publish rates. The company's billing rules engine draws on data from its provider network, which it describes as covering more than 30,000 billing rules. Reviewers note that the service does not resolve every denial type, and some claims are returned to the practice for handling rather than fully worked by athenahealth.

CareCloud's Concierge service covers coding, claims submission, denial management, and collections as a full outsourcing arrangement, positioned around AI-assisted automation. Third-party estimates put Concierge pricing at 3% to 7% of collections plus setup fees; these figures are not confirmed by CareCloud. The company also sells Central, its practice management and EHR software, at an estimated $349 per provider per month, also unconfirmed. Across 112 GetApp reviews, CareCloud holds a 3.6 out of 5, the weakest and most polarized rating in this comparison, with 22 one-star reviews among the total. Reviewers praise the modern interface and integrated billing, and report bugs, crashes, and inconsistent support.

Vendors combining software, clearinghouse, and outsourced billing

AdvancedMD, DrChrono, and NextGen Healthcare each combine more than one of these models under a single company, letting a practice choose how much billing work to keep in-house.

AdvancedMD sells billing software with an integrated clearinghouse, built around tools it calls ClaimInspector and an A/R Control Center, and also offers outsourced RCM either through its own in-house team or through a network of more than 800 independent contractors it calls "AdvancedBillers." Pricing is not published; third-party estimates put the software around $729 per provider per month, with outsourced RCM at 4% to 8% of collections, neither confirmed by the vendor. Reviewers praise the interface but describe reliability problems, with one writing that the system "is down a lot," and describe support that reviewers say declines after implementation is complete.

DrChrono, now owned by EverHealth/EverCommerce, sells EHR, practice management, and billing software built around an Apple and iPad-first design, and offers optional outsourced RCM through in-house billers, DrChrono's own RCM team, or a hybrid of the two. Sixty-five percent of reviewers work in small-to-midsize practices. DrChrono has three pricing tiers with amounts that are not published, plus a listed $1.00 fee per paper claim. Across 492 GetApp reviews, DrChrono holds a 3.9 out of 5. Reviewers like the cloud access, customizable workflows, and Apple-oriented design, and report bugs, outages, slow support, and complaints tied to billing and claims processing.

NextGen Healthcare covers all three models under one roof: billing software inside its practice management suite, its own clearinghouse and EDI connectivity, and outsourced RCM split into two tiers, an Enterprise RCM offering for practices with ten or more providers and an Office RCM offering for practices under that size. Pricing is not disclosed, and public review volume specific to the RCM service is thin compared with the other vendors covered here, which limits how much can be said about its reputation with confidence.

The outsourced-versus-in-house cost question

The best-sourced figures in this comparison put outsourced RCM pricing in a fairly narrow band: athenaCollector at 4% to 8% of collections, CareCloud's Concierge at 3% to 7%, and AdvancedMD's outsourced option at roughly 4% to 8%, all third-party estimates rather than vendor-confirmed numbers.

Broader industry guides go further. The American Billing Association, for example, puts outsourced billing at 3% to 10% of collections overall and estimates the fully-loaded cost of an in-house billing operation, including salary, benefits, software, and overhead, at 8% to 15% of collections. Those numbers should be read with the source in mind: they come from a trade group representing billing companies, which have a direct financial interest in making outsourcing look favorable by comparison. No strong, neutral, independently audited statistic comparing in-house and outsourced billing cost appears to exist publicly, and that gap should be stated directly rather than filled in with a vendor's number presented as neutral fact.

Questions to ask before signing with any vendor

The Change Healthcare outage changed what a reasonable vendor evaluation looks like. Price, integration, and support quality still matter, but the events of 2024 add a second set of questions that practices had little reason to ask before:

• What is the vendor's plan if its own systems go down for an extended period, and how long is that plan designed to hold, measured against the AHA's benchmark of 30 days?
• Does the contract include an exclusivity clause that would prevent routing claims through a second clearinghouse during an outage?
• How long would payer EDI and ERA re-enrollment take with a backup clearinghouse, given that this step, not software setup, was the actual bottleneck for most practices in 2024?
• What would a temporary or permanent switch cost in setup fees and any per-claim surcharges, stated in writing rather than estimated after the fact?
• Does the vendor, or does the practice itself, maintain a second, tested connection to at least one alternative clearinghouse, following the dual-vendor approach Jackson Health System adopted after the outage?
• Are staff cross-trained on a backup system, so that a switch does not depend on one employee's familiarity with a single platform?

None of this replaces ordinary diligence on price and features. But a comparison written before 2024 would have stopped at price and features, and the survey data above shows what that omission cost practices when a single vendor concentrated so much of the country's claims processing in one place.