Healthcare electronic data interchange (EDI) is a structured way to exchange healthcare information in a standardized format between two facilities such as providers, payers, clearing houses, pharmacies, suppliers, and manufacturers. Healthcare EDI applies to documents such as claims, medical billing, health records, purchase orders, invoices, and shipping notices, as well as other important or classified healthcare-related information.
The competitive landscape includes the analysis of key growth strategies such as product offerings and business strategies adopted by major players to expand their presence and increase their shares in the global healthcare EDI market.
Visionary companies include players that have an established product portfolio coupled with a strong geographic and market presence. These companies offer advanced and reputable services & solutions and also focus on maintaining and upgrading them. The abovementioned companies are also known for their well-established geographic presence and a widespread distribution network. They are known to adopt strong business strategies to increase their foothold in the market.
Dynamic players have strong business strategies but a weaker product offering as compared to the other players in the market. CThese companies have the potential to broaden their product portfolio to compete with other key market players.
Innovators demonstrate substantial product innovation as compared to their competitors and have a focused approach towards enhancing their product portfolio.They have innovative solutions & services and the potential to build strong strategies. However, as compared to the vanguards, they do not have very strong growth strategies for their overall business development.
These vendors focus on providing niche products to gain recognition in the market. They have the potential to build a strong product portfolio and business strategy to compete in the market with the vanguards and innovators. However, they might be new entrants to the market and require some more time before gaining a significant position in the market. Healthcare providers comprise large as well as small hospitals, independent physician offices, clinics, and other healthcare centers. Healthcare providers use EDI for claims processing, eligibility verification, payment remittance, enrolment and disenrollment transactions, referral certification authorization, and premium payments. A number of provisions of the Affordable Care Act (ACA) have resulted in an increase in the number of population health management programs being implemented in the U.S. The ACA stresses on value-based reimbursement and quality of treatment rather than the traditional fee-for-reimbursement systems based on volume. Healthcare EDI solutions for providers help in the exchange of patient information and intelligent clinical decision support among providers & payers, and the management and assessment of health outcomes for a broad patient population. Healthcare payers are entities other than patients that finance or reimburse the cost of health services. They are among the key end users of healthcare EDI solutions. Typically, payers deal with an enormous amount of patient data for claims processing, wherein they are required to interact with healthcare providers and clearinghouses to enable an efficient payment process and ensure maximum claims being provided for the healthcare service rendered by the healthcare provider to the patient. EDI has been regarded as a tool for payers to minimize errors and reduce administration costs associated with claims processing. In the U.S., the use of EDI was enforced on payers and providers with the implementation of the Health Insurance Portability and Accountability Act (HIPAA) transaction standards. The requirements set forth by HIPAA compelled healthcare payers to use electronic means for claims processing with the payer, which led to its immediate adoption by healthcare payers. EDI is used by payers in the international healthcare markets; however, lack of defined communication standards presents a major hurdle for its greater implementation. Pharmacies use EDI services for retail pharmacy claim transactions and pharmacy inventory management. Retail pharmacy claim transactions are used by pharmacies to submit claims to payers, either directly or through clearinghouses. EDI services are used to render claims for retail pharmacy services and billing payment information between payers or between payers and regulatory agencies to monitor rendering, billing, and payment of retail pharmacy services. EDI interface in pharmacy inventory management enables a pharmacy to order inventory through a pharmacy EDI software. The transaction reaches the wholesaler who then sends an order confirmation (EDI 855). Inventory management through EDI is an accurate and efficient way to procure and manage the supply chain. The need to reduce the overall costs and human typing errors associated with healthcare supply chain management in pharmacies are the major factors driving the growth of this end-user segment.