By Serkan Kutan, Chief Technology Officer, Price Optimization at Zelis
In today’s healthcare ecosystem, the pressure to reduce costs is intense—but the path forward isn’t just about cutting spend. It’s about transforming how claims are processed, priced, and resolved. That transformation starts with artificial intelligence.
At Zelis, we believe claims accuracy is foundational to a better healthcare experience. But accuracy today demands more than manual review—it requires intelligent automation, explainable AI, and expert validation. That’s why we’re investing in next-generation solutions that blend scalable technology with human oversight to deliver faster, more defensible outcomes.
The Claims Challenge
Health plans are facing a perfect storm: rising medical loss ratios, mounting regulatory demands, and increasingly complex claims. According to Zelis’ State of the Healthcare Financial Experience study:
- 77% of payers say delivering healthcare is not getting easier, citing rising costs, technology fragmentation, and administrative complexity.
- 96% of payers rely on multiple solutions for payment integrity.
- Yet only 23% are actively using AI to improve these workflows.
This fragmentation leads to inefficiencies, disputes, and delays—especially when claims are routed through siloed systems with inconsistent data, manual processes and higher denial rates. What payers need now is not just AI—but AI they can trust, AI that’s trained for defensible payment accuracy
A Smarter Way Forward
At Zelis, we see a powerful opportunity to reimagine how AI supports claims accuracy and payment integrity. As healthcare continues to evolve, payers are seeking solutions that go beyond automation— they’re prioritizing systems that enhance decision-making, reduce friction, and align with the realities of modern care delivery.
We believe the future lies in a hybrid model: AI-assisted, expert-validated. This approach blends scalable automation with human oversight to ensure every claim is processed with speed, precision, and compliance.
Looking ahead, we envision AI playing a central role in:
- Claims routing that accelerates validation and uncovers high-impact savings opportunities in out-of-network workflows
- Generative AI that can rapidly configure new claims edits from client documentation, accelerate line-item analysis, and extract SOPs from medical records
- Enterprise-grade analytics that synthesize structured and unstructured data to support context-aware, defensible decisions
Our AI models now review tens of millions of claim lines monthly, surfacing anomalies with explainable precision and audit-ready traceability. These AI capabilities supported by deep clinical expertise help payers maximize claims workflows without sacrificing efficiency and provider trust”. The path forward isn’t just about adopting AI—it’s about designing systems that elevate it into a trusted partner.
Turning Tension Into Trust
Claims inaccuracies don’t just cost money—they erode trust. Disputes over coding, pricing, and compliance create tension between payers and providers, draining resources and delaying care.
But when claims are optimized for accuracy from the start, everyone benefits. Administrative burden decreases. Disputes decline. And payer-provider relationships strengthen through shared understanding and aligned expectations.
What’s Next
Payers are intrigued by AI but cautious. They want transparency, explainability and real operational impact. And they need solutions that go beyond incremental fixes—solutions that modernize the entire claims lifecycle.
We’re not just building tools—we’re building trust. And we’re laying the foundation for a future where every claim is optimized by AI, validated by experts, and tailored to the needs of every stakeholder.
The next chapter in claims optimization is coming. And at Zelis, AI isn’t just a pilot – it’s already transforming how every claim is priced, validated and resolved.