What It Means to Modernize the Healthcare Financial Experience

By Amanda Eisel

Amanda Eisel has focused the last 20 years of her career at the intersection of healthcare and technology. She has been deeply involved creating and scaling multiple growth technology companies including Waystar, Applied Systems and Viewpoint. Amanda has been a member of the Zelis team since 2019, playing a leadership role across Zelis’ growth, operational and talent strategies. Amanda started her career at McKinsey & Company, where she spent nearly a decade advising consumer companies. Prior to Zelis, Amanda was an Operating Partner at Bain Capital focused on technology and healthcare IT companies.

I want to talk with you about something big we’re doing at Zelis: modernizing the healthcare financial experience by building something remarkable: a connected platform that bridges the gaps in the financial system and aligns the interests of payers, providers, and members, so everyone benefits.

It’s our commitment to redefining the way this industry delivers value to its stakeholders. Value which is ultimately derived from a more seamless experience with the business side of healthcare. 

Why does this matter? 

First, data shows that the financial experience of healthcare is often as important as the clinical one. The impact of friction and confusion with the business aspect of healthcare can be monumental on outcomes for patients and their families. 

This, in turn, has an impact on the healthcare system that’s twofold; patients who delay care often face delayed diagnoses or worsening health conditions, which is also more resource and cost-intensive on the system. Patients often skip scheduled appointments due to fear of cost, locking up vital resources in an already strained system and ultimately costing $150 billion annually. 

That burden cannot be overstated. 

Second, we also know that striving for a more seamless experience will have financial benefits as efficiency naturally drives savings. 

Modernizing the financial experience in a system that moves at paces varying from glacial to that of a rushing river (typically when the government gets involved), takes all of us – not just Zelis, but also amazing clients and partners who are just as committed to a better way. 

Exciting news 

By way of this blog, I’m excited to share two exciting bits of news – both centered in making a difference in how people experience healthcare but from different ends of the spectrum.

The first is the business side. 

The payment integrity aspect of how claims are adjudicated by payers is one in dire need of modernization. This necessary aspect of managing healthcare claims submitted by care practitioners is often performed solely after the payment has been sent – talk about antiquated. Imagine being on either side of the conversation to claw back money for services rendered and paid. Painful. 

Second, this process is usually conducted by at least three parties to account for any possible savings based on fragmented libraries of rules. 

Third, these activities are often carried out in a “black box” where clarity into what contract rules have been applied is vague at best. 

Lastly, add in market dynamics such as Change Healthcare’s divestment of ClaimXten. What an opportunity for transformation. One which we’re zealously tackling, notably with our recent acquisition of PayerCompass and an aggressive roadmap towards automating most manual claim review with artificial intelligence.

As such, I’m excited to unveil the third installment of the pioneering study we commissioned with Aite-Novarica earlier in 2022 – Payment Integrity and Cost Containment in Healthcare. This groundbreaking benchmark study had participation from 214 payer executives, offering an outline for the next wave of payment integrity between payers and providers. 

This outline covers a few of the problems I discussed earlier – namely, a shift from post-payment to more pre-payment review to prevent those messy overpayment situations, a need for automation to address the roughly 80% of manual entry occurring today – particularly in DRG review, and a requirement for overall better communication with healthcare providers. 

Not only does this report offer an outline in and of itself, but there’s also an accompanying self-service diagnostic to receive a more personalized assessment of where one’s organization stands in the path towards harmony and modernity in payment integrity practices. 

I challenge you to take the test. And to explore all the harmonization index material here.

Equally important, or even more so, is our commitment as an organization and as individuals to contribute to the cause with our culture. 

I’ve talked before about the ZelisCares initiative, a 6-pillared person-centric wellness program and our Business Resource Groups, such as the Women of Zelis. And this month, they’re teaming up for the ultimate challenge – the Susan G. Komen Foundation’s Race for the Cure. 

One in eight women will be diagnosed with breast cancer in her lifetime, an incredibly difficult diagnosis to receive from both emotional and financial perspectives. Breast cancer treatment can be extremely expensive, even for those who have health insurance. 

In 2019, people paid higher out-of-pocket costs for breast cancer care than for any other type of cancer care — a total of $3.14 billion. The cost to the overall system is even higher, clocking in at over $20 billion annually as of 2020. 

People with breast cancer often struggle with both loss of income while taking time away from work and care-related costs they didn’t anticipate. Bills and debt can pile up quickly, causing some people to skip or delay treatments. It’s common for the financial burden to last for years and to affect a person’s whole family.

Breast cancer awareness is close to my heart, as I lost my own mother to this devastating disease. I’m incredibly proud to see our Zelots coming together to support this cause – many of whom have already clocked in tens or even hundreds of miles. 

Together, we’re helping this incredible organization improve the lives of people with cancer, all while strengthening the health of our Zelis community and driving down costs for the system.

The wrap up

Many companies are talking about transforming the business of healthcare, but we’re taking action through our business practices and investments, as well as by supporting causes which have downstream impact on the health of people and the financial system.

For regular updates on our progress, follow Zelis on LinkedIn. 

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Until next time, stay well!