Pricing operations in healthcare today are grappling with issues reminiscent of the early days of electronic medical records (EMRs). In the 1990s and early 2000s, EMR systems were fragmented across departments—emergency rooms, radiology, labs—each functioning in isolation. That same siloed approach now impedes progress in pricing and revenue cycle operations.
To explore these challenges and the role of emerging technologies in solving them, Becker’s Healthcare spoke with Jay Deady, President of Price Optimization at Zelis.
Silos and Inefficiencies
Mr. Deady began his career during the initial wave of EMR adoption. He recalled a time when providers used 12 to 14 separate EMR systems—one for each clinical department—leading to significant fragmentation across organizations.
Interfaces were eventually developed to share limited data between systems, but these solutions were often incomplete and inefficient. Patient data remained scattered and inconsistent.
Over time, integrated EMR platforms emerged, improving data sharing and coordination. These comprehensive systems enabled a more connected and holistic view of a patient’s clinical status.
According to Mr. Deady, fragmentation has long driven up costs and inefficiencies in healthcare—first in clinical operations, and now in pricing. Revenue cycle leaders are increasingly aware of this issue and feel a growing urgency to address it.
“On the revenue cycle side, where we are today is pretty similar to where the EMR industry was a few decades ago,” Mr. Deady said.
Several factors are heightening that urgency. As healthcare becomes more consumer-focused and members grow more digitally savvy, there’s rising demand for holistic solutions that simplify the financial side of care.
“The industry is under a lot of pressure right now,” Mr. Deady said. “Cutting costs and increasing efficiency is a big focus for payers.”
Regulatory demands are also accelerating change. Federal and state-level regulations are pushing for fair pricing practices and an end to surprise billing, prompting health plans to seek more effective pricing solutions.
Technology Enables ‘Balanced Pricing’
Modern pricing operations rely on a combination of advanced technologies, robust data, and expert oversight. Together, these elements are creating a more seamless and connected financial experience across the care continuum.
Zelis offers multiple pricing optimization solutions—including in-network and out-of-network pricing, as well as payment integrity services to verify coding accuracy and pricing, especially for complex, high-cost procedures.
“Our approach is to take in a single claim and be able to offer all those solutions, which provides a multiplier effect,” Mr. Deady explained. “Just like having one EMR platform, Zelis is providing one platform for pricing and claims integrity operations.”
Zelis minimizes friction by applying multiple AI and data layers to arrive at a “balanced price” that considers the needs of all stakeholders: members, providers, and payers.
Mr. Deady addressed a common misconception—that health plans aim to extract every penny from a claim. In reality, plans are deeply concerned with member and provider satisfaction. Their goal is to reduce abrasion, foster positive relationships, and meet the needs of all parties.
Achieving balanced pricing requires consolidated data and integrated technologies—not a patchwork of disconnected systems.
“It gets communication out faster to the provider and to members in terms of what they may owe,” Mr. Deady said. “Providers benefit from faster speed and greater transparency, and members benefit from greater savings.”
The Future of Pricing Operations
Dealing with out-of-network healthcare bills can be challenging for members, causing confusion and unexpected financial strain. This often leads to decreased member satisfaction and increased frustration for employer groups. To help, Zelis offers Health Bill Assist®, a free service for members of Zelis clients. It designed to address these issues by offering specialized out-of-network bill support.
A major trend in healthcare is personalized medicine—tailoring care to individual patients rather than applying a one-size-fits-all approach. Mr. Deady sees similar potential for personalization in pricing and revenue cycle operations.
Because patients have diverse financial situations, advanced technologies can enable personalized solutions. For example, one patient might receive a discount for paying in full, while another might be offered an interest-free loan to spread payments over time.
“We need to move to a more personalized revenue cycle to match the personalized medicine that we’re seeing on the clinical side,” Mr. Deady said. “We’ve achieved millions of dollars in savings for members, and it’s because of the technology and the capabilities of our platform.”
