The cost of healthcare in the United States has been rising steadily for decades, with citizens now spending more than $3 trillion each year.

New Jersey–based Zelis Healthcare has helped healthcare payer clients across the United States save more than $24 billion in network and claims costs using advanced technologies and expert clinical resources to reduce errors, waste, and abuse. Zelis also makes more than $19 billion in timely, accurate payments to healthcare providers, helping convert the more than $500 billion in paper-based healthcare payments to more efficient, effective, electronic payments.

With more than 800 dedicated associates across nine locations nationwide, Zelis integrates network analytics and design, network access and cost management, claims cost management and electronic payments to serve payers, healthcare providers, and consumers in the medical, dental, and workers’ compensation markets nationwide. Zelis drives market-leading performance by deploying advanced technologies and leveraging secure, streamlined cloud innovation to optimize healthcare cost management and payment processes.

Building the next-generation platform

Innovating and changing the way people think about the healthcare claims cost management process is key to the company’s overall strategy. With the next-generation Zelis Intelligent Claims Routing Platform based on Microsoft Azure, Zelis improves efficiency, effectiveness, and accuracy of the processes necessary to help control the rising cost of healthcare. Zelis focuses on removing errors, waste, and abuse from claims post-adjudication and prepayment by leveraging proprietary technologies and expert clinical resources with an integrated, centralized, and digital infrastructure.

Historically, healthcare cost management processes have been deployed after payment for a claim is made to a healthcare provider. This approach can be ineffective, and often delays the process of determining claim cost appropriateness. The company’s’ proprietary technologies speed up the cost management process and enable determination of claim cost appropriateness before claims are paid. These advanced technologies help Zelis to lead the way forward in the healthcare payment integrity industry.

“When we look at a claim, we take a 360-degree view,” explains Doug Klinger, CEO of Zelis Healthcare. “We deploy proprietary technologies and expert clinical resources to identify network cost savings along with clinical and specialty clinical claims cost savings, while leveraging technology to optimize claim workflows. This combination of activities is executed in parallel to deliver market-leading transparency, efficiency, and cost saving effectiveness on every network, every claim, every payment, every day,”

Key objectives

Key objectives for the Zelis Intelligent Claims Routing Platform are to:

• • Maximize network and claims cost savings opportunities for payers by further identifying hard-to-detect instances of errors, waste, and abuse in network and claims costs before they are paid.
  • Deliver customized, actionable insights to healthcare payers to help them further maximize network and claims cost savings.
  • Accelerate evolution of next-generation cost management technologies.

Zelis considered the full range of available cloud solutions before deciding that Azure was the best fit. Between Azure platform as a service (PaaS) offerings and the approach Microsoft takes to technology licensing, Zelis found that it could provide the agility and cloud capabilities to develop a highly secure solution tailored to its unique needs. In addition, the ability of Azure to support a hybrid solution allowed the company to maintain productivity and avoid costly downtime.

“We are very excited about leveraging proven, scalable, integrated platforms enhanced by Azure functionality,” says Thiyagu Gnanasekaran, Senior Vice President of Enterprise Application Development at Zelis. “We look forward to continuing to collaborate with Microsoft on innovative solutions to serve our clients.”

Measurable results, at every level

Planning for the solution’s digital architecture, including Azure Data Lake Analytics capabilities, began in early 2018, and the solution was designed, built, and launched in mid-2018. The cloud technology powers the foundation for a scalable platform.

“We serve nearly 600 healthcare payers, from the largest national payers to regional health plans and third-party administrators in the medical, dental, and workers compensation markets. We’re focused on delivering our trademark better service and better performance through capabilities that new technology provides,” Gnanasekaran adds.

Innovation improvements, affordable healthcare

Reducing the rising cost of healthcare is a long-term challenge for the United States. “We are on a mission to help make healthcare more affordable. This type of transformative technology will help us make that possible and will benefit everyone,” concludes Klinger.