Waystar vs Availity vs Change Healthcare for $40M RCM
After the Change Healthcare attack, $40M RCM firms need to pick a primary clearinghouse without betting everything on it. Here is how the three compare.
TL;DR. At $40M RCM, the question is not which clearinghouse is best. It is which one you run as primary and which one you keep ready when the primary goes down. Waystar wins on denial prevention but costs more. Availity wins on payer coverage and price but has weaker scrubbing. Change Healthcare under Optum is back online and full-featured, but you cannot trust your entire claims pipeline to it anymore. The pattern that works post-2024: primary plus warm backup, with the dollar volume split deliberately.
If you run revenue cycle for a $40M billing company or a 50-doctor practice management group, the clearinghouse question got harder in February 2024. Before the attack, "use Change Healthcare" was the default answer for half the market. Now you need a real decision. Here is what each of the three looks like from the operator's seat, what they actually cost, and the configuration that holds up when the next one gets hit.
What broke in 2024, and why it matters for $40M shops
Change Healthcare processed about half of all U.S. medical claims when the ALPHV/BlackCat ransomware group took it down on February 21, 2024. According to a March 2024 American Hospital Association survey, 94% of hospitals reported economic strain, 33% said the attack disrupted more than half of their revenue, and 60% needed two weeks to three months to fully restore normal operations. UnitedHealth Group, Change's parent, ended up loaning money to providers who could not collect claims fast enough to make payroll.
For mid-market RCM firms, the lesson was concrete. A $40M billing company running 90% of claims through one clearinghouse is one bad day from a payroll problem. The 2025 TriZetto breach (3.4 million patient records) made it worse. It is not a Change-specific risk, it is a clearinghouse-concentration risk.
So the question stopped being "which clearinghouse" and became "which primary, which backup, and how do I split the dollars." That is the frame for the rest of this post.
Waystar
Waystar went public on NASDAQ in June 2024 and now processes over 7.5 billion transactions annually for more than 1 million providers, per its 2025 10-K filing. It earned Best-in-KLAS 2025 for clearinghouse, narrowly edging Experian Health (91.8 vs 88.4).
What it does well. Waystar's AltitudeAI denial-prevention engine has prevented an estimated $15.5 billion in denied claims across its book. Practices that switch from rule-based scrubbing typically report a 15% to 25% reduction in denial rates, which is the difference between a 12%-denial shop and an 8%-denial shop. On a $40M book of net patient revenue, that is roughly $1.2M in recovered revenue per year, against subscription costs that run $200 to $800 per month or $0.20 to $0.35 per claim depending on volume.
Where it falls short. Implementation is not a weekend. Mid-market RCM firms that have switched typically run a 60 to 90 day overlap with their prior clearinghouse, because the AI predictions only get good once it has seen 30+ days of your specific payer mix. The price band is also wide enough that you need to negotiate hard. $0.35 per claim at 200K claims per year is $70K, while $0.20 per claim at the same volume is $40K, and the line between those tiers is not always visible until you ask for it specifically.
Best fit. Primary clearinghouse for a $30M+ RCM firm whose denial rate is north of 10% and whose payer mix is diverse. The AI savings compound at volume.
Availity
Availity runs one of the largest multi-payer health information networks in the US, connecting over 3 million providers with more than 2,000 trading partners and covering 95%+ of US payers. The provider portal is free. Availity was co-founded by Humana, Blue Cross Blue Shield of Florida, and several other major payers, which is why the payer network is so broad.
What it does well. Coverage and price. The free tier handles eligibility verification, claim status, and ERA retrieval for nearly every payer a mid-market RCM firm will ever touch. After the Change attack, Availity launched a Rapid Recovery cybersecurity standard in February 2025 and became FHIR-native ahead of the CMS-0057 prior-auth final rule deadline. They also picked up the KLAS Points of Light 2025 award for their digital tools.
Where it falls short. Scrubbing. The claim edits on the free tier catch formatting errors and missing fields, but they do not flag subtle modifier issues or predict denials the way Waystar's AI does. If your denial rate is already under 8% because your coders are sharp, the free Availity scrubbing is fine. Above 10%, you are leaving money on the floor.
Best fit. Warm backup clearinghouse for any RCM firm, and primary for budget-constrained shops with strong in-house coding. The free portal also doubles as a payer-lookup tool when you need to verify eligibility outside your primary system.
Change Healthcare (Optum)
Change Healthcare, now operating under Optum (UnitedHealth Group), has completed its post-breach security upgrades and resumed full operations. It still processes nearly 15 billion transactions annually and offers the most comprehensive integrated suite of any vendor on this list, covering clearinghouse plus payment integrity, eligibility, prior auth, and patient financial services.
What it does well. Breadth. If your RCM firm needs a single vendor for claims, eligibility, ERA, patient statements, and payment posting, Optum has the deepest catalog. The integration into the broader Optum and UnitedHealth ecosystem also matters for any firm with significant UHC payer volume. Direct API access to the payer side cuts a real amount of phone-tree time.
Where it falls short. Concentration risk. The product is fine. The vendor concentration is the problem. The Becker's Hospital Review one-year retrospective on the cyberattack documented multiple mid-market RCM firms that lost two to three months of cash flow during the outage, and most of them have since either left Optum entirely or capped its share of their volume at 30% or less.
Best fit. One leg of a multi-clearinghouse strategy for firms with significant UHC payer volume. The integrated suite is genuinely useful. Just do not route 90% of your claims through it anymore.
The comparison at $40M RCM
| Factor | Waystar | Availity | Change Healthcare (Optum) |
|---|---|---|---|
| Best role | Primary | Backup or budget primary | Specialty leg of split |
| Pricing | $0.20-$0.35/claim or $200-$800/mo | Free portal, paid add-ons | Custom, enterprise |
| Denial-prevention AI | AltitudeAI (industry leading) | Basic scrubbing | Optum suite (integrated) |
| Payer coverage | Broad, 200+ EHR integrations | 95%+ of US payers | Deepest UHC integration |
| Post-2024 security posture | No known incidents, SOX-compliant | Rapid Recovery standard 2025 | Recovered, but burned trust |
| Implementation time | 60-90 days for AI tuning | Days to weeks | 30-60 days |
| Resilience play | Use as primary | Always keep as backup | Cap at <30% of volume |
The factor that gets underweighted in vendor pitches is implementation time. The AI on Waystar gets dramatically better once it has 30 days of your payer mix. The Optum integration gets dramatically smoother once your team learns the workflow. If you switch primaries mid-quarter, your collection rate will drop for the first 4 to 6 weeks before it recovers. Plan the switch around your slowest collection month, not your busiest.
What to actually pick
For a $40M RCM firm with diverse payer mix and a denial rate over 10%, the configuration that holds up is: Waystar as primary (60% to 70% of volume), Availity as warm backup (10% to 15%) and free utility for eligibility, Optum for the UHC-heavy specialty (15% to 20% if you have meaningful UHC volume, zero otherwise). The split costs more than running single-vendor, but the math works at $40M scale. A single 30-day outage on a single-vendor setup costs more than a year of the extra subscription on the split.
For a $30M shop with denial rates already under 8% and tight margins, the configuration shifts. Availity as primary, Waystar only for the highest-value commercial payers where the AI catches the most expensive denials, Optum as third only if you have UHC concentration. The free Availity tier plus targeted Waystar usage runs roughly $15K to $25K per year against $40K to $70K for full Waystar primary.
The configuration to avoid: 90% on any one vendor. The 2024 and 2025 breaches both targeted vendors with that kind of concentration, and the operators who got hurt were the ones who had not split their volume. As the broader healthcare RCM AI roll-up plays out, expect PE-backed buyers to specifically scrutinize clearinghouse concentration during diligence.
"Our technical clearinghouse was down, and that's about 90% of our revenue. The second piece, which we identified later that day, was that our patient payment platform was down, so patients were also unable to make payments. The system was completely inaccessible to both our patients and our team members to be able to collect payments."
VP of Revenue Cycle, Moffitt Cancer Center, on the 2024 Change Healthcare outage (AHIMA Journal)
FAQ
Can a $40M RCM firm switch clearinghouses without disrupting cash flow? Yes, if you run a 60 to 90 day overlap and switch during your slowest collection month. The expensive mistake is trying to switch in three weeks at end-of-quarter to "save the subscription cost." The collections dip during the transition will cost more than the overlap subscription.
Does Availity's free tier actually work for a real RCM firm, or is it a loss leader? The free tier works for eligibility verification, claim status, ERA retrieval, and basic claim submission for almost every payer. What it does not do well is denial prevention through smart scrubbing. If you pair it with strong coders or a separate scrubbing tool, the free tier is genuinely production-grade.
How much does the AI denial prevention from Waystar actually save? The reported range is 15% to 25% denial reduction. On $40M in net patient revenue with a starting 12% denial rate, dropping to 9% recovers roughly $1.2M in collected revenue per year. The subscription costs $40K to $70K. Net savings $1.1M to $1.15M, assuming you actually work the cleaner queue.
Is it worth running three clearinghouses instead of two? For most $40M firms, no. Two is enough resilience: a primary and a warm backup. Three creates operational drag (three vendor relationships, three sets of edits to maintain, three contracts to negotiate). The three-clearinghouse split only makes sense if you have a specialty payer concentration that justifies a third dedicated route (heavy UHC, heavy Medicaid in one state, or similar).
What does "warm backup" actually mean operationally? It means the backup clearinghouse is configured, has signed enrollment for every payer you bill, has your team trained on the workflow, and is processing 10% to 15% of your claims on an ongoing basis. A "cold" backup that you configure after your primary goes down takes two weeks to enroll with payers, which is exactly the window where you bleed cash.
If your RCM operation is running 90% through a single clearinghouse and you have been meaning to fix it since February 2024, that is the project to scope. We build the workflows that route claims across multiple clearinghouses, the dashboards that monitor each vendor's submission and ERA pipelines, and the AI scrubbing layer that sits in front of all of them. Fixed price, four weeks, working tool at the end. Book 30 minutes with us and tell us your current vendor mix and denial rate, and we will show you what the split would look like for your firm.
Keep Reading
- How $40M RCM Firms Cut Claim Denials From 18% to 8%: The workflow changes that drop denial rates before you upgrade the clearinghouse, applied at a mid-market revenue cycle firm.
- Why Healthcare RCM Is the Next Mid-Market AI Roll-Up: The PE thesis driving consolidation in mid-market RCM and what it means for vendor selection at $40M.