Jay Deady, President, Claims Cost Solutions at Zelis.
Healthcare is evolving at breakneck speed, especially with the rise of AI. Yet many healthcare organizations, in particular health insurers, are still tied to legacy systems and complex internal IT structures. The result is a growing gap between what’s possible and what’s practical. But if history has taught us anything, it’s that with partnership and perseverance progress is possible.
Healthcare payers face mounting pressure to modernize. The same forces that drove providers to adopt platform electronic medical records (EMR) decades ago—regulatory complexity, compliance demands and rapid tech evolution—are now knocking on the payer’s door.
The question is no longer can you maintain custom systems, but should you?
It’s time to shift the conversation away from incremental change and toward strategic transformation. Rather than vie for quick tech wins, the focus should be on sustainable growth and innovation. The result? Better member experience, operational efficiency and accelerated value.
Three Strategic Shifts For Healthcare IT Modernization
1. Reframe The Mission From IT Builders To Care Coordinators
Over the last decade, payers have been forced to evolve into quasi-IT companies by maintaining large internal teams to support custom-built systems that require constant updating. It’s time to acknowledge what many leaders already know: This model is no longer sustainable. Having worked with prominent organizations and technology leaders for over 30 years, I urge leaders to reassess their core mission.
Are your organization’s systems mainly focused on helping members access the right care when they need it, or maintaining code?
Ask yourself:
• Does our mission align with our current technology investments?
• Are we building an ecosystem of partners that support long-term transformation?
• Can our staffing model support the pace of change?
• Is our cost structure optimized for innovation?
Acknowledging where things may have gone off course (and where external expertise is needed) is the first step toward reclaiming time, resources and strategic clarity.
2. Recognize Regulatory Pressure As A Catalyst
Regulatory and compliance demands are intensifying. From the No Surprises Act to Independent Dispute Resolution processes, payers are navigating a complex and evolving landscape. On top of that, mounting litigation, policy shifts and data privacy concerns are reshaping the rules of engagement. With AI accelerating the pace of technological change, the cost of maintaining outdated systems rises exponentially.
Rather than viewing compliance as a burden, treat it as a signal: It’s time to modernize. For example, consolidated platform solutions can offer a scalable, future-proof way to meet these demands while reducing risk and complexity.
3. Invest In Strategic Partnerships And Platform Solutions
In-house solutions had their moment, but today’s complexity—from claims to compliance—calls for a new approach. Solutions must be smarter and more scalable.
Platform solutions offer a way to achieve these goals. Platform solutions unify fragmented workflows, reduce vendor sprawl and boost ROI. Instead of juggling dozens of disconnected tools, payers can consolidate claims, payments and data into one system that’s easier to manage and faster to evolve according to their needs and speed.
For example, a modernized claims platform can automate processing, flag anomalies in real time and integrate with payment systems—all while staying compliant.
To get there, look for an expert partner that will guide discovery, align workflows and build custom solutions that scale with your organization.
Strategic partners bring deep healthcare expertise to help you:
• Integrate platforms without losing valuable customizations
• Replace manual tasks with automation like real-time eligibility checks
• Centralize data governance to reduce compliance risk
• Navigate regulatory nuances and interoperability standards
Modernizing IT infrastructure is a strategic shift, not just a tech upgrade. Payers gain efficiency, providers benefit from streamlined processes, and members acquire lower costs and better service.
First Steps To Consider
To get started:
1. Conduct a technology audit to identify redundancies, inefficiencies and compliance gaps.
2. Engage stakeholders across departments to align transformation goals.
3. Evaluate platform vendors based on scalability, interoperability and healthcare-specific expertise.
4. Start small with pilot programs that demonstrate quick wins and build momentum.
The Bottom Line
Healthcare payers are at the same crossroads providers faced years ago. The combination of regulatory pressure and exponential tech growth demands a new approach. By combining in-house expertise with platform capabilities, organizations can achieve the agility, compliance and scalability needed to lead in a fast-changing healthcare environment.
Creating a culture of change starts with recognizing the moment and acting on it. It means moving beyond short-term fixes and embracing long-term transformation. It means empowering teams to focus on care coordination and member outcomes, not just system maintenance.
The future of healthcare IT isn’t patchwork, it’s platform, and the organizations that make the shift now will be best positioned to thrive in tomorrow’s landscape.
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