Payer Concentration
🛡️ Public data only — no PHI permitted on this instance.
Payer Concentration Tracker
CR1/CR3/CR5 · HHI · renewal schedule · denials · NSA OON exposure — 1,455 corpus deals
Revenue
$250M
Top Payer
21.7%
CR3
49.5%
CR5
68.0%
HHI
1,213
Commercial
59.4%
Risk Profile
DIVERSIFIED
Corpus Deals
1,455
Payer Revenue Share Distribution
Payer Roster — Share, YoY, Contract Expiry, Denials, Renewal Risk
| Payer | Type | Net Rev ($M) | Share | YoY | Expiry | Denial % | DAR | Renewal Risk | Status |
|---|---|---|---|---|---|---|---|---|---|
| BlueCross BlueShield Assoc | Commercial National | $54.17 | 21.67% | +2.0% | 2027Q3 | 12.0% | 42 | 45 | mid-term |
| UnitedHealthcare | Commercial National | $39.00 | 15.60% | -1.0% | 2026Q2 | 6.0% | 47 | 36 | at renewal |
| Medicare FFS | Federal | $30.47 | 12.19% | +5.0% | 2027Q2 | 4.0% | 45 | 29 | mid-term |
| Aetna / CVS Health | Commercial National | $26.00 | 10.40% | +0.0% | 2026Q1 | 5.0% | 46 | 20 | at renewal |
| Medicare Advantage (Blended) | MA Risk | $20.31 | 8.13% | +8.0% | 2027Q1 | 4.0% | 34 | 24 | mid-term |
| Medicaid Managed Care (Blended) | Medicaid MMC | $18.62 | 7.45% | +9.0% | 2027Q4 | 10.0% | 51 | 23 | mid-term |
| Cigna | Commercial National | $17.33 | 6.93% | +0.0% | 2026Q3 | 11.0% | 52 | 13 | at renewal |
| State Medicaid FFS | Medicaid FFS | $13.54 | 5.42% | +7.0% | 2027Q4 | 13.0% | 43 | 35 | mid-term |
| Anthem / Elevance | Commercial Regional | $11.92 | 4.77% | -1.0% | 2027Q4 | 13.0% | 43 | 32 | long contract |
| Humana MA | MA Risk | $10.16 | 4.06% | -3.0% | 2027Q2 | 7.0% | 37 | 17 | long contract |
| Self-Pay / Private | Self-Pay | $5.08 | 2.03% | +2.0% | 2026Q3 | 13.0% | 54 | 18 | at renewal |
| Tricare / VA | Federal | $3.39 | 1.35% | +0.0% | 2026Q1 | 10.0% | 40 | 20 | at renewal |
Concentration Metrics vs Benchmark
| Metric | Value | Benchmark | Variance | Interpretation |
|---|---|---|---|---|
| Top Payer Share | 21.67% | 25.00% | -3.33pp | above 40% is material concentration risk |
| Top 3 Payer Share (CR3) | 49.46% | 60.00% | -10.54pp | above 75% signals oligopolistic exposure |
| Top 5 Payer Share (CR5) | 67.99% | 82.00% | -14.01pp | above 90% is typical for mid-market HC |
| Herfindahl Index (HHI) | 1,213 | 1,800 | -587 | HHI >2500 = concentrated; >1800 = moderate |
| Payer Count | 12 | 10 | +2 | healthy diversification above 10 payers |
| Weighted Denial Rate | 8.38% | 8.00% | +0.38pp | target <8%; >12% is a red flag |
| Weighted Days in AR | 44.4 | 42.0 | +2.4 | target <42 days blended |
Contract Renewal Calendar — Priority & Exposure
| Payer | Expiry | Annual Rev ($M) | Type | Rate Reset | Exposure | Priority |
|---|---|---|---|---|---|---|
| Aetna / CVS Health | 2026Q1 | $26.00 | Commercial National | CPI+1.5% floor, max 4% | 10.4% | high |
| Tricare / VA | 2026Q1 | $3.39 | Federal | state-set | 1.4% | standard |
| UnitedHealthcare | 2026Q2 | $39.00 | Commercial National | CPI+1.5% floor, max 4% | 15.6% | critical |
| Cigna | 2026Q3 | $17.33 | Commercial National | CPI+1.5% floor, max 4% | 6.9% | high |
| Self-Pay / Private | 2026Q3 | $5.08 | Self-Pay | state-set | 2.0% | standard |
| Medicare Advantage (Blended) | 2027Q1 | $20.31 | MA Risk | state-set | 8.1% | high |
| Medicare FFS | 2027Q2 | $30.47 | Federal | state-set | 12.2% | critical |
| Humana MA | 2027Q2 | $10.16 | MA Risk | state-set | 4.1% | standard |
| BlueCross BlueShield Assoc | 2027Q3 | $54.17 | Commercial National | CPI+1.5% floor, max 4% | 21.7% | critical |
| Medicaid Managed Care (Blended) | 2027Q4 | $18.62 | Medicaid MMC | state-set | 7.4% | high |
Payer-Level Denials Analysis — Write-Off Exposure
| Payer | Denial % | Top Reason | Days to Overturn | Overturn % | Write-Off Exposure ($M) |
|---|---|---|---|---|---|
| BlueCross BlueShield Assoc | 12.0% | No Referral | 28 | 72.0% | $1.82 |
| UnitedHealthcare | 6.0% | Duplicate Claim | 23 | 65.0% | $0.82 |
| Medicare FFS | 4.0% | Medical Necessity | 39 | 60.0% | $0.49 |
| Aetna / CVS Health | 5.0% | Prior Auth Missing | 46 | 70.0% | $0.39 |
| Medicare Advantage (Blended) | 4.0% | Timely Filing | 34 | 73.0% | $0.22 |
| Medicaid Managed Care (Blended) | 10.0% | Place-of-Service Mismatch | 33 | 59.0% | $0.76 |
| Cigna | 11.0% | No Referral | 28 | 75.0% | $0.48 |
| State Medicaid FFS | 13.0% | Eligibility Lapse | 41 | 70.0% | $0.53 |
Out-of-Network Exposure by Service Line — No Surprises Act
| Service Line | OON Volume % | Avg Coll Rate | Balance-Bill Risk ($M) | NSA Impact |
|---|---|---|---|---|
| Emergency Medicine | 12.0% | 48.0% | $1.85 | NSA-protected; arbitrage risk |
| Anesthesia (hospital-based) | 18.0% | 52.0% | $2.40 | NSA-protected; QPA disputes |
| Radiology (hospital-based) | 8.0% | 55.0% | $0.85 | NSA-protected |
| Pathology | 14.0% | 50.0% | $1.20 | NSA-protected; arbitrage ongoing |
| Ground Ambulance | 22.0% | 42.0% | $0.95 | NSA-excluded state balance bill |
| Air Ambulance | 68.0% | 35.0% | $0.45 | NSA-protected; very high dispute rate |
| Specialty Drug Administration | 6.0% | 58.0% | $0.55 | buy-and-bill; minimal OON |
| Outpatient Surgery | 4.0% | 62.0% | $0.40 | NSA-protected for non-elective |
Payer Risk Thesis: Concentration profile = diversified.
Top payer holds 21.7% of revenue; top 3 hold 49.5%; HHI 1,213.
$5.51M in write-off exposure from denials ($3.13M concentrated in top 3 payers).
$8.65M balance-bill risk under No Surprises Act. Material contract renewals in the next 4 quarters demand rate-reset
strategy and in-parallel 2nd-payer development to reduce CR1 before exit.