Healthcare leaders often describe the payer-provider relationship as adversarial. Yet new findings discussed in this episode suggest a different reality: the industry’s biggest stakeholders largely agree on the challenges standing in the way of a better financial experience. Rising costs, workforce shortages and administrative complexity rank as top concerns for both groups, signaling that alignment on the problem may be stronger than many realize.
In this conversation, Yusuf Qasim, president of payments optimization at Zelis, explores why that alignment has not yet translated into meaningful progress. While both sides possess extensive data and analytical capabilities, collaboration around cost, quality and operational insights remains limited. The result is persistent friction across claims, payments, denials and reconciliation workflows, where manual work continues to consume time and resources.
Qasim argues that the opportunity is not necessarily to create new systems, but to better share information that already exists. From reducing avoidable administrative burdens to improving transparency around payments and coverage information, he outlines practical areas where payers and providers can begin building trust, improving efficiency and delivering better outcomes across the healthcare ecosystem.
Transcription
Speaker:
You’re listening to a sponsored episode of Podnosis.
Irena Luo:
Welcome everyone. You’re listening to Podnosis: the pulse of the healthcare industry. I’m your host, Irena Luo. I’m joined today by Yusuf Qasim, president of payments optimization at Zelis. Welcome, Yusuf. Thank you for sitting down with me today.
Yusuf Qasim:
Thank you, Irena. Really excited for the conversation and I appreciate you having me on today’s discussion.
Irena Luo:
Absolutely. So in today’s conversation, we’re going to unpack why alignment on the problem doesn’t really mean alignment on the fix. We’ll discuss where the gaps continue to show up inside payment workflows and outline the concrete stuff payers and providers can take now to move from shared diagnosis to shared results. So, Yusuf, I’m just going to dive right in. Can you tell us about your state of the healthcare financial experience report and what findings really stood out the most and what does it really mean for the industry today?
Yusuf Qasim:
Yeah, Irena. So in our second annual state of the healthcare financial experience, first, I was thrilled we were able to survey more than 500 payer and provider leaders. That’s typically unheard of. And I think the report really examined what’s driving the pressure behind this payer provider relationship. It outlined where alignment exists, but also where the friction I think continues to persist and what the data says about the path forward. I think what surprised me the most about this year’s survey was actually how much common ground there is. Everyone thinks there is a side to be one, but the data actually says the complete opposite. And when you start to unpack what the results are, both groups rank the same three issues at the top. I mean, we literally surveyed them independently, but the irony is they both service those three issues and those three in order for both groups were rising costs, workforce shortages and administrative complexity.
And 98% of the payers and 95% of the providers agree that reducing the friction between them is a shared responsibility. So it was actually a very interesting outcome of this report. While folks may think they’re speaking a different language or focus on different things, they are saying the exact same thing in different ways. And so while typically payers and providers don’t agree on everything, I think each side is feeling the costs of the system differently from opposite ends of the transaction. And I think from there, the story necessarily isn’t conflict, it’s really just two groups describing one problem. And I think just one last point on that, I think the finding I keep coming back to is both sides believe their relationship is improving and they expect it to keep improving, not just they expect it. We are now at a time where the relationship does need to improve. And I think in a relationship where the industry loves to call this adversarial, no one’s expecting it to get worse. They’re all really leaning in to make it better.
Irena Luo:
Yeah, definitely. And it sounds like payers and providers really share the biggest challenges that we are facing in healthcare, but we’re not seeing that collaboration on cost and quality data. So where should they start collaborating first and what is one concrete step that each side should take to make that happen?
Yusuf Qasim:
Yeah, oftentimes when I get the benefit of talking to both payers and providers, the one non-controversial thing is the amount of data that both parties have. In addition to that, I think what this report highlighted is they both agree they have significant amount of analytical capabilities. So there’s no shortage of data and there’s no shortage of making sense of the data. I think the biggest opportunity is to connect more of those insights across the organizations, not necessarily hoarding it, but actually surfacing it up because I think, again, back to the data, 86% of the payers and 81% of the providers conduct fraud, waste, and abuse analytics. 80% and 92% conduct claims and trend net analysis.
So every day folks are actually conducting a lot of claim trend analysis on their own data. And in addition to that, a significant portion are also conducting utilization review. And so what I take from this is everyone’s running analytics, but no one’s running them together. And so while they have these strong capabilities, the one thing that’s not necessarily happening is that collaboration on the cost and quality front. And both again, would agree that sharing data across these entities ranked the lowest for both groups. So roughly less than half of the payers and providers are actively saying that they share this data. So I think it is a huge opportunity in terms of what to do next, given the fact that this is not a data problem.
Irena Luo:
Yeah, no. When we talk about the healthcare industry, we all talk about everyone works in silos. So it’s really breaking down those silos to ensure that there is that true collaboration and sharing of data to really try to make sense so that they could both move forward that same direction, right?
Yusuf Qasim:
100%. And I think again, just to really hit this point, they both agree they are operating very siloed. So again, the alignment, it’s all there. I think this next evolution and really kind of peeling back the next layer of this is to now sort of lean in and have what I’m going to call the trust fall of sharing what’s comfortable. But I think with that share and that collaboration, it’ll start to unlock even more, I think, trust within the system and get to the same result.
Irena Luo:
Absolutely. So your findings show a significant gap in how manual work is distributed when payments don’t process cleanly. What part of that workflow is most right for improvement today and what should payers and providers do differently there?
Yusuf Qasim:
Yeah, I think there’s two dimensions. Obviously we really focus on the digital and modern experience of healthcare, but I would say digital payments itself isn’t the end all be all. When a payment doesn’t land cleanly, the manual work doesn’t necessarily disappear. It just shows up somewhere else in the workflow. And so I think with that, one significant opportunity is sort of that connection between the payment, the remittance information and the provider workflow required to truly post and reconcile. I think for payers, they can really help by making sure payments arrive with the transparency and again, the data behind them, the information that providers need to understand and reconcile them officially. And if that’s actually not happening, unpack it resolving it because I think again, there’s a lot of tools, technology and capabilities that already exist, but perhaps they’re not realizing there’s a lot of manual processes happening behind the scenes for their providers.
I think similarly for providers, they can really help identify the reoccurring exception patterns and bring those trends back to the payers rather than resolving the same issues, either one transaction at a time or again, within their walls. Just to kind of go down a little bit of a rabbit hole, we oftentimes try to connect our payment delivery with our payer and provider customers. And oftentimes we’ll show a provider in saying, “Hey, are these data, are these insights really powerful for you?” And they’re like, “Unequivocally yes.” And similarly, we’ll service the same data set for our set of payers, for the providers.
And many teams are like, “I would love to have this.” And we ask, “Would you mind if this data was accessible to the other side?” And I would’ve thought the answer would’ve been no. The answer is unequivocally yes, because most of the administrative burden and a lot of the bottlenecks that either the payer or the provider see is them trying to chase each self down for that actual visibility, that transparency or clarity. So again, back to that point, the data is there. Everyone’s raising their hand and saying, “I want to get rid of these manual workflows, a lot of the administrative burdens.” And when you start to unlock that and share it across, everybody wins in that equation.
Irena Luo:
Yeah. Yeah. No, absolutely. So if a payer and provider wanted to make really meaningful progress in the next six to 12 months, what would be the first two or three changes you would ask them to prioritize?
Yusuf Qasim:
I think I’d start with the workflows where both sides already have information. So we’re not creating anything necessarily new or anything controversial. Healthcare has existed for a long time. A lot of these data assets have existed for a long time, but sort of really leaning in where there’s a lot of rework or where there’s a lot of manual intervention. I think that’ll, number one, create a lot of value quickly and it’ll start to build confidence in building that trust in that next sort of layer that I talked about. In terms of I think three tangible examples, first, like I said, target the administrative fiction directly. So the fragmented workflows that can be avoidable that have a lot of cost amongst the two entities, I think is first order in terms of priority.
So cleaner intake, clearer documentation, faster eligibility decisions. These are just some little examples that I think can reduce that noise across the spectrum. I think number two, just making sure cost and coverage information is easier to understand. Back to the report, 96% of providers said helping patients understand their coverage is critical, but only 29% of them rate themselves as effective. A, that’s a very honest rating, but again, this is information that is easily accessible for payers. And so how do we start to bridge that disconnect? Because ultimately both sides are trying to solve for that coverage and visibility scenario. And then I think third, it comes back to that analytical or the analytics and data that I talked about earlier.
I think moving from parallel analytics to shared insights in a small number of targeted use cases, I’m going to emphasize small number of targeted use cases, I think will create so much more unlock because again, I think everyone’s trying to tackle the same problem differently. And where that really could make a difference is around claims and prior auth. I think those are good starting points because both already have the relevant information, both are experiencing some of the consequences when these workflows sort of break down. And again, it’d be sort of an easy win to really start to elevate the relationship across the payer provider dynamic.
Irena Luo:
I love that. And I love those three key points that you highlighted that both sides could really work on to ensure there’s that collaboration that’s needed to really ensure those fixes are attended to. So to just pivot to the next question and looking at some of the friction points, denials, appeals and claim errors remain major friction points for both sides. What does a better operating model for addressing these issues look like and who really needs to be involved? What information needs to be shared and where should organization even begin to tackle that?
Yusuf Qasim:
Yeah, this is a massive pain point in healthcare right now. I’d love to wonder if I was telling what are people using more of the word AI or denials? I think for us at Zelis, the best denial is the one that never happens. And that’s because better information is available. There are better processes to catch things upfront. And literally every stakeholder, we’ve been talking about payers and providers, but I’m now going to add the member and/or the patient. Literally the best denial is the one that never happens and it can be done. And that’s associated around claims errors, appeals. Again, I’m just using that bucket, but it is amongst the clearest area of shared concern in this research. I’d say roughly half of both the payers and providers cite them as the top source of friction while also prior auth delays are also significant for both groups.
But I think again, a better operating model starts really upstream before the claim even reaches the appeal stage. And so I think for both payers and whether they’re using their payment integrity teams or your provider and you’re more on the RCM team or the coding team, I think looking together at those reoccurring patterns, undeniably, you could reduce so much noise and inconsistencies in the system because ultimately we know the data’s there, we know these are addressable. And again, in our early days of sharing some of our preliminary denial and analytics for our provider customers, oftentimes these are just things that, again, are getting missed or there’s a manual workaround that didn’t necessarily meet the standards of the payers. And everyone would win if we reduced that overall denial rate that’s happening that we’re seeing across the system.
Irena Luo:
No, absolutely. So you mentioned AI and there’s definitely no shortage of technology that’s being added to help improve the healthcare workflow and to alleviate administrative burden. What metric should payers and providers track to know whether a new solution is actually reducing friction, manual work, and even distrust?
Yusuf Qasim:
I think before we touch on what new metric, I think when it comes to technology, I think both stakeholders adopting new tools, I think the real test isn’t really in any new tool necessarily. When you think about the manual work that’s supposed to go away, I think that’s the biggest test. I mean, right now, if you go back, cost and workforce shortages is some of the biggest drivers of the friction that’s in the system. So before even analyzing a new tool and seeing some of the efficiency, I think there’s just so much opportunity in the manual work and the time that it takes to actually facilitate and process claims is probably the biggest driver because I’ll just give you that one little example for when we had shared some denial and claims insights for our providers, we oftentimes went to the payers and said, “Here’s the data that we’re showing.” The number one thing they said is the minute you show that, two things are going to happen.
Number one, where we’re seeing a lot of friction where we should not be denying these claims, hopefully we’re giving or Zealous is giving providers the insights to address maybe what’s missing from a data perspective. Number two is we’re going to see so much less calls in our call center. And so again, I’m just giving you one little example where it’s not necessarily adopting new tools, but leveraging the tools and the data that is already available, making it actionable, but the net result is significantly less manual work. I think that is one of the biggest KPIs and metrics that folks, if they’re not already adopting, they should, and they should be pressure testing that every day because that’s going to be the forcing function to actually optimize and fix the system.
Irena Luo:
Amazing. And Yusuf, thank you so much for sitting down with me today and sharing data from the State of the Healthcare Financial Experience Report and also sharing insights on what payers and providers really need to do to move forward and collaborate and aim towards that same goal that we all talk about.
Yusuf Qasim:
Thank you, Irena. I know we could talk probably for another half hour, hour on this topic. I mean, it is a big one. It is a big focus area, not just for Zelis, but for the industry. I’ll probably end in how I started. The beauty of this report is there is no shortage of alignment in the industry regardless of who you are. And again, this data allowed us to actually really unpack what’s driving this behind the scenes. So even if the entities and the parties are not talking as much as we’d like, they share a common goal and I think that creates a lot of optimism for healthcare. It creates a lot of optimism for Zelis and all the tools and capabilities and datas that we’re looking to bring. And I think it’s going to be exciting rest of 2026 as well as 2027 given the alignment that we’re seeing across all the stakeholders.
Irena Luo:
Well said. Thank you, Yusuf. Thank you for listening to Podnosis. You could find more about this topic in our show notes at fiercehealthcare.com. Look for our podcast and don’t forget to tune in every Wednesday morning to Podnosis where healthcare is our beat.