Just about every vendor in the payment integrity space says they minimize provider abrasion. Saying it is very different to doing it. As a practicing physician and CMO, I want to address that head on. Providers don’t just want a verdict on a claim—they want to understand the “why” behind claim edits and pricing decisions, see the sources and logic, and have a fast, human path to resolution when questions arise. That’s exactly where Zelis is focused. And it’s why our strategy puts the payer-provider relationship at the center of payment integrity.

What providers need—and why it matters

Administrative complexity remains the single largest source of waste in U.S. healthcare, with credible estimates placing the category at $265.6 billion annually.  At the transaction level, providers shoulder 97% of the $83 billion spent each year on routine payer-provider administrative tasks like eligibility checks, prior auths, and claim follow-ups. It’s no surprise, then, that clinicians want less opacity and more clarity: clear edit logic, understandable remittance messages, and actionable guidance that prevents rework.

The industry knows there’s room to improve. The 2024 CAQH Index highlights a $20 billion savings opportunity if we automate and streamline core admin transactions — time and dollars that can go back to care. Meanwhile, physicians continue to report that opaque, manual processes can delay or derail care: 93–94% say prior authorization delays necessary treatment; 82% say it can lead to treatment abandonment; and ~29% report serious adverse events associated with PA. Those are not abstract statistics – they are daily realities in clinics and hospitals.

Why payers struggle to go it alone

Payers face a complex, moving target: evolving coverage policies, fast changing clinical guidelines, and escalating scrutiny on improper payments. For example, CMS pegs 2024 Medicare FFS improper payments at 7.66% ($31.7B), emphasizing that most are due to missing administrative steps or insufficient documentation — not fraud.  At the same time, initial denial rates have climbed and stayed high — averaging around 12% in 2023 across hospital claims.

The downstream effects are straining payer-provider relationships. HFMA surveys show nearly 60% of hospital CFOs say those relationships have worsened in recent years, citing surging denials and lack of transparency as primary drivers; they rank greater clarity into payment rules and behaviors as a top lever to repair trust.  And when denials do occur, providers collectively spend ~$19.7B a year trying to overturn them; roughly 15% of commercial and Medicare Advantage claims are initially denied, yet over half are ultimately overturned — after costly, time-consuming appeals. 

The takeaway: payers need a partner who can protect payment integrity and deliver the transparency, education, and hands-on support providers are asking for — without adding abrasion.

Our framework: Payment integrity that strengthens relationships

At Zelis, we’ve built a physician-informed approach to payment integrity centered on “enable, educate and engage” — a practical framework designed to make claim decisions understandable and sustainable for providers while giving payers confidence that the right payment is made the first time.

Enable: Make decisions transparent and navigable

  • Provider Communication Toolkits: When clients activate new prepay edits, we supply plain language announcement templates and FAQs so networks hear changes directly and clearly—before claims are impacted.
  • EOB/Remittance Clarity: We align remark messaging to industry standards (CARCs/RARCs) and provide crosswalks when codes evolve, so providers can trace each adjustment to an edit rule and take the correct next step. 
  • Edit Transparency: Edit explanations reference industry standard sources and clinical guidelines, so a coder, biller, or clinician can see exactly why a line item was adjusted.

Educate: Prevent repeat abrasion

  • Provider Coding Guidebook: Authored by our coding and dispute resolution experts in consultation with me as CMO, this living resource covers the most commonly disputed scenarios—documentation tips, outpatient billing nuances, and guidance on unspecified/laterality codes—so future claims get submitted cleanly the first time.

Engage: Resolve questions quickly, with experts

  • Expert dispute resolution team: We handle >100,000 provider calls per year on behalf of clients and resolve inquiries in <15 days, backed by a 95%+ review sustainability rate on complex reviews.
  • Rightsized inquiry handling: Typical inquiry/dispute rates after claims editing: 0–5% for general claims edits; 5–10% for clinical coding policy/genetics; and 0–10% for expert reviews like itemized bills or DRG validations—driven lower by proactive enablement and education.
  • Measured impact: As new edits mature with our provider enablement, clients adopt ~16% more recommended edits while disputes drop >25% over the first two years.

This is what provider facing support looks like in practice: anticipatory communication, standards aligned remittance messaging, practical coding guidance, and rapid, expert human support when questions remain.

How this helps both sides—clinically and financially

For providers, clarity reduces rework and accelerates cash flow—without sacrificing coding and claims accuracy. For payers, it means fewer avoidable denials and appeals, fewer abrasion driven escalations, and better network stability. It also aligns with a broader push toward administrative efficiency that leading organizations (and clinicians) have called for to reduce waste and return time to patient care. 

And importantly, our approach complements, rather than complicates, the regulatory push for clearer, computable remittance communication and interoperable, standards based information sharing across the ecosystem. (If you’ve ever had to decode a paper remit to figure out a payer’s decision path, you know why those standards matter.

The bottom line

Payment integrity should never be a black box. Providers deserve to see the edit logic and pricing rationale that payers apply to their claims, to understand it in the language of clinical documentation and coding, and to have an easy path to resolution when something doesn’t add up. Payers, for their part, deserve a partner who can shoulder the operational lift, reduce abrasion and protect dollars without damaging relationships.

At Zelis, we built our Enable–Educate–Engage model precisely for that purpose. It’s physician led, standards-aligned and proven in the field. If you’re ready to put the payer-provider relationship at the center of payment integrity — and get better outcomes on both sides — we’re ready to help.