Healthcare IT Today Podcast: 4 Opportunities to Ease the Tension Between Payers & Providers

When it comes to providers and payers, there’s no avoiding the tension that exists between the two. Ultimately, one’s revenue is the other’s costs. There’s also the fact that providers and payers are optimizing for different things. Providers want to ensure patients get the best care. Individual clinicians are incentivized to provide more care at the individual level to serve the patient and avoid malpractice suits; at the institutional level, more procedures mean more revenue, typically. Payers, on the other hand, face their own competitive dynamics as they sell to employers and individuals who want low premiums above all else. 

You might be surprised to learn that despite the inevitably of this tension, there also lies plenty of opportunity in the space between providers and payers. In a recent episode on Healthcare IT Today Interviews, Steve Rowe, Healthcare Industry Lead at 3Pillar, and host John Lynn discuss why this tension exists and what can be done about it. We’ve captured the four biggest opportunities below.

The first opportunity is around Revenue Cycle Management (RCM) and claims. Payers have all sorts of different rules around what they will approve and what they’ll deny to balance the tension between keeping premiums low and paying for medical coverage. These rules are sometimes even group-specific. 

The challenge? Providers don’t know what those rules are, which creates difficulties for the member. It’s not easy to understand at the moment what will be approved and what will be denied. That means patients may end up unhappy when a proposed treatment is denied or not paid in full (and they are balanced billed).

The opportunity here is for payers to expose that logic to health systems—essentially preadjucating payment (instead of doing it after the fact). The business rationale: make it easy for in-network providers to get paid in exchange for more competitive rates. Some companies are already doing this:  “Glen Tullman is doing it with Transcarent; he’s essentially trying to intermediate the payer to create a new network. His whole premise to providers is, ‘Join our network because we will pay you the same day you do service,’” notes Steve. “That’s how he’s building his network with the top healthsystem and doctors.”  

In Steve’s experience building an RCM startup and working with a regional Urgent Care chain, he observed that the expertise and institutional knowledge around claims processing was largely in the heads of the medical billing coders. 

There are two main forms of complexity in RCM he highlights:

1. Submitting the correct eligibility information (e.g. specific formatting of member ID numbers)
2. Matching the right diagnostic codes to the appropriate CPT codes, which can be a large and complex matrix.

The risk here is that this institutional knowledge will be lost when these experienced medical billers retire. The processes are very manual, with reimbursements not keeping up with labor inflation. 3Pillar is leveraging AI and data mining to reverse engineer each payer’s algorithm for approvals and denials. The goal is to systematize this knowledge and flag issues proactively, rather than relying on the institutional knowledge of the billing staff.

The vision is to integrate this RCM intelligence engine with clinical documentation tools. That way providers are alerted in real-time during the care planning process about treatments or codes that are likely to be denied by the payer. This will improve the financial experience for providers and patients alike.

There is a significant opportunity for data transformation as regional payers have data that lives in separate systems that don’t talk to each other. The pipes to connect these systems haven’t been built and the data isn’t defined in the same way. Regional payers are often at a technological disadvantage compared to national payers because they still have on-premise servers and haven’t moved to the cloud. The IT departments for these payers are swamped putting out fires. They simply don’t have the resources to take on the work associated with major technology modernization projects.

And here’s the rub: Self-insured employers want highly customized insurance products and plans that require flexible and configurable technology platforms. National payers have invested in modern tech stacks that can support this level of customization. However, regional payers struggle to match this same capability. 

So, there’s a real need for regional payers to create a unified data platform and operating system that can integrate data from various systems (e.g., claims, population health, PBM, etc.). This would result in a simplified member experience while enabling seamless workflows for call center representatives, who often have to navigate multiple disparate systems. This is an area where working with a partner who specializes in this capability would be beneficial. 

Speaking of member experience, it’s now the number one concern of Vice Presidents of Benefits at self-insured employers thanks to a tight labor market. Top-tier benefits are necessary to attract and retain talent. There’s no doubt that there’s plenty of room to improve. The experience is often fragmented and frustrating as members struggle to get accurate information about coverage, costs, and provider networks. 

There’s an opportunity for payers to make their medical policies and coverage algorithms more transparent and accessible to members at the point of care. Steve explains, “I’m excited about this opportunity because we’ve all been there where it’s like, ‘I just want to know if this particular provider for urgent care who is still open at 10 p.m. is in network. I can’t figure that out on the app. There’s not a search function and the call line doesn’t open until 8 a.m. tomorrow.”

What if patients could get real-time answers to their questions? 3Pillar is making that vision a reality through chatbots powered by AI and knowledge graphs. By using AI to combine data from disparate systems, members can get accurate, up-to-date information at any time, from anywhere.

These chatbots could also help to address the challenge of call center representatives needing to navigate multiple systems to piece together an answer for a member. Steve points out one key consideration: ensuring the chatbots are fed accurate data and avoiding hallucinations. Doing so requires careful design and integration with the underlying data sources. 

While none of these opportunities have “easy buttons” to press, they all provide means for payers to differentiate themselves and better serve patients and providers. You can discover even more areas for payers and providers to win in the full podcast episode. 

How to Reduce Cloud Costs Without Impacting Performance

Cloud technology is the primary way CIOs, CTOs and their departments can generate value in their organizations. Yet more and more eyes are on the expenses associated with cloud computing, according to the Bureau of Labor Statistics’ Producer Price Index (PPI), which cites a 3.7% year-over-year increase (September 2022 to September 2023).

With increased pressure to cut costs, tech leaders need ways to reduce the price of cloud without sacrificing the performance and flexibility the technology is known for. 

There are practical ways to reduce cloud costs without sacrificing performance, and it starts with understanding the 3 main drivers.

We like to look at cloud costs by bucketing them into 3 categories: minor, medium, and significant. 

1. Minor cost drivers: These costs are more commonplace and will add up over time. 
2. Medium cost drivers: These expenses often require more strategy to mitigate. 
3. Significant cost drivers: These require the most skill to mitigate. 

Within these three categories, you’ll find both visible and hidden costs. Visible costs are those that are billed regularly (such as on a monthly billing statement) and are well known by stakeholders. For example, software licensing fees would be considered a visible cost. They’re typically easier to track and manage as needed.

Hidden costs, on the other hand, are more likely to go unnoticed. They only draw attention when they start to truly impact the budget. An example of a hidden cost would be a logging service with significant verbosity. Capturing more detail than needed for troubleshooting can increase your storage costs over time.

As you review these categories and consider how your budget may be impacted by these drivers, keep in mind that the effect is often cumulative. So, you may choose to tackle several minor cost drivers that are adding up to significant pressure on your budget first to gain some momentum and buy-in with leadership. Or you may choose to dive into a significant cost driver first to realize savings as quickly as possible. 

Now that you know which categories your cloud cost drivers fall into and have some practical ideas for addressing them, let’s take a look at some best practices for cloud cost optimization across the board. 

Rightsizing is key to cutting waste and reducing costs. Over-provisioned resources can quickly inflate a budget, but that’s just the start. Bilal Hasan Khan, Associate Director at 3Pillar, notes, “Tech leaders often underestimate cloud cost management, thinking rightsizing is enough. Hidden costs, however, can significantly impact budgets.” A holistic approach—including audits, FinOps, and automation tools—helps reduce expenses while improving performance without compromising quality or service.

If you don’t have a visible budget for each cloud service, that’s your starting place. Each cloud service should have financial guardrails with stakeholders held accountable for monitoring related expenses against those budgets. 

This is one area where automation can help with optimization. Consider tools that will flag costs outside your budgeted range, adjust resource allocation, and identify any idle resources. 

Unite your finance and technology teams under a Financial Operations (FinOps) framework. This cultural and operational approach maximizes the value of cloud investments. Building a FinOps culture requires a roadmap, clear roles, best practices, and strong collaboration. The FinOps Foundation outlines three maturity stages: Crawl, Walk, and Run

Optimizing cloud costs often leads to better performance. Instead of just cutting costs, you’re ensuring cloud investments add value. This boosts efficiency by preventing over-provisioning, increasing scalability, reducing waste, and shifting focus to innovation.

At 3Pillar, we offer tailored solutions to help organizations maximize the impact of their cloud investments. As a trusted software development partner, we specialize in digital product development, cloud cost management, and optimization. Our expert team has successfully implemented cost-saving strategies for clients across many different industries. Contact us to learn how we can help optimize your cloud costs.

Bilal Hasan

Associate Director, Global Head Automation Practice

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Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 1)

How does Cisco produce one of the best-integrated cybersecurity platforms in the world? Jason Cyr, VP and Head of Product Design at Cisco, joins The Innovation Engine to talk with 3Pillar Field CTO Lance Mohring about how design is deeply embedded in Cisco’s product development process.

Jason walks us through the market and organizational context that shapes Cisco’s unified product design process, which frequently involves incorporating new products to the overall product mix in the wake of an acquisition. He then gives some specific details on how product design can improve cybersecurity by preventing everyday configuration errors, while also anticipating zero-day vulnerabilities.

Jason outlines the Cisco product, design, and engineering team’s unique GOAT process, which stands for Give Outcomes A Try and is influenced by Josh Seiden’s book Outcomes Over Output. The GOAT process allows product managers, engineers, and designers to identify and align on end-user outcomes before the iterative development process even begins.

Our conversation is so meaty we had to break it up into two parts. Be sure to stay tuned for Part 2 next week, where we’ll dive into how Jason anticipates AI will impact product design in the near future and much more.

Listen to this episode of The Innovation Engine on Apple Podcasts, Spotify, or via the embed below.

• Jason gives a firsthand account of the modern history of cybersecurity product design
• Jason explains how product design can reduce cyberattacks
• The story of how the Cisco team created their Give Outcomes a Try (GOAT) process and the impact it has had

• Connect with Jason Cyr on LinkedIn
• Connect with Lance Mohring on LinkedIn 
• Check out Jason’s blogs on Medium
• Read “Outcomes Over Output” by Josh Seiden
• Listen to Ep. 197 of The Innovation Engine: How to Drive Outcomes Over Outputs, with Josh Seiden

Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 2)

Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 2)

Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 2)

Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 2)

Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 2)

Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 2)

Product Design in Cybersecurity, with Jason Cyr of Cisco (Part 2)