Recent disruptions in healthcare payment networks have exposed not just a cybersecurity failure but a structural vulnerability. Many of these networks are contracted to have a single authorized pathway, creating a hidden concentration risk. Clearinghouses can reroute transactions, but only when multiple pathways are permitted. SmartBrief recently spoke with Rob Stuart, president and CEO of Claim.MD, about how to build strategic redundancy into the system at the network and contracting level.
How are medical transactions traditionally handled, and what are the risks of this approach?
Medical transactions have traditionally relied on highly centralized routing structures that depend on a primary clearinghouse or transaction pathway to manage claims, eligibility, remittance and other administrative exchanges. While this model has historically created operational efficiency, it has also introduced concentrated points of dependency across the healthcare ecosystem.
The risk of this approach becomes most visible during disruption. When a primary transaction pathway becomes unavailable, the effects extend far beyond delayed claims processing. Revenue cycles can slow or stop entirely, operational burdens increase and providers may face challenges maintaining financial continuity. Ultimately, disruptions in administrative infrastructure can affect patient care by diverting staff attention, delaying reimbursements and creating uncertainty across the healthcare system.
What lessons have we learned from recent industry disruptions?
What recent events have reinforced is that efficiency alone cannot be the defining principle of transaction infrastructure. Organizations must also evaluate resilience, continuity and the ability to maintain operations when disruption occurs.
Resilience must be designed into the system at the network and contracting level, not left to providers to navigate during a crisis. Resilience is not just about preventing failure but designing systems that can continue operating when failure occurs.
Another important takeaway is that responsibility for continuity cannot rest solely with providers navigating challenges in real time. Resilience must exist at the network, vendor and contracting levels, as well. Medium to large-scale payers should be evaluating/re-evaluating contracts with clearinghouses that create exclusivity in contracting, so as not to concentrate the risk again.
What is strategic redundancy, and how does it fit into the evolution of healthcare payment networks?
Strategic redundancy is the intentional design of multiple viable transaction pathways—in this case, maintaining access to more than one clearinghouse partner—so healthcare organizations can maintain continuity during disruption.
In many other critical industries, redundancy has long been recognized as a standard component of infrastructure design. Healthcare transactions have historically evolved differently. Administrative networks were often built around centralized structures designed primarily for efficiency and scale. Over time, that created environments where many organizations became dependent on a limited number of pathways or vendors.
Recent industry events have highlighted the need to evolve beyond that model toward more resilient transaction ecosystems that incorporate interoperability, routing flexibility and continuity planning as foundational components of infrastructure strategy.
Strategic redundancy for clearinghouse contracting and pathways helps create a more balanced and resilient ecosystem by ensuring organizations maintain options, interoperability and continuity rather than becoming overly dependent on any single pathway or gatekeeper.
What steps can payers take, both internally and during contracting, to minimize risk?
Re-evaluate current routing and vendor structures and engage in conversations about how to build more resilient infrastructure. Payers can begin by evaluating their current transaction environments to better understand where dependencies exist. This includes identifying whether critical processes rely too heavily on a single vendor, routing structure or operational pathway.
During vendor and payer contracting cycles, questions around alternate routing capabilities, transaction portability, operational flexibility and contingency planning should become standard components of infrastructure evaluation. While smaller payers may not be able to financially support multiple clearinghouses, medium to large-scale payers should not be without these sorts of back-ups.
Payers should ask clearinghouses key questions about redundancy during contracting cycles:
- Is there more than one authorized pathway?
- Are alternatives contractually allowed?
- What happens during prolonged disruption?
It is important to move beyond theoretical redundancy and focus on operational readiness. Alternate pathways should be actively maintained, scalable and capable of supporting production-level transaction volume if needed. Organizations should understand not only whether alternatives exist, but how quickly they can be activated and what operational limitations may emerge during extended disruption scenarios.
Many organizations still operate within transaction environments where routing flexibility is limited, alternate pathways are not fully operationalized and dependency remains concentrated among a small number of entities. Without broader adoption of strategic redundancy, healthcare continues to face the possibility that a single cyberattack, outage or operational failure could once again create widespread disruption across the ecosystem.
The question now is whether the industry uses the lessons from the 2024 cyberattack to build more resilient infrastructure, or whether it accepts continued vulnerability to the same type of event in the future. It’s time to start a conversation.