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PERSPECTIVES


MAKING A BETTER FUTURE FOR CLAIMS MANAGEMENT

GE Healthcare's John Zimmerman wants to help ease provider pain

Tell us about your role and responsibilities at GE Healthcare.

My role is general manager of GE Healthcare Digital’s Value-Based Care Division. I manage the global P&L for all of our products and services that help customers deal with the transition to value-based care. This includes everything from revenue cycle management to EMR, workforce management and population health.

Before GE, you spent time at Allscripts, CareFusion, Siemens Healthcare—how did you first become involved in the healthcare industry?

It goes back a long time. I had the great fortune to work with IBM in my formative years. I was a systems engineer when IBM tapped me on the shoulder and asked if I would take on a new role in IBM. My job was to understand IBM’s direction and translate that direction across to selected accounts across the country. One account was this huge entity that served the healthcare industry: Shared Medical Systems. It later became Siemens. My account created many strategic businesses and opportunities that are still paying dividends today—25 years later.

Over your career, you’ve helped to shape many technology innovations. Which one stands out in your mind the most, and why?

The one that I am most proud of still works today. I was part of the team that helped invent the national electronic data interchange (EDI) network way back when. Payers and providers could exchange information seamlessly because of the use of standards between them. Something had to be created to sit in the middle as an information brokerage and clearinghouse. We invented that for online eligibility verification.

What led you to focus on the claims aspect of healthcare?

Provider pain that information technology can help to solve. If you don’t get the appropriate information from a health plan about a patient and provider encounter, the payer has the right to deny payment. Even though the care was legitimate, the information flow is incorrect and incomplete. Providers will suffer from that. We are committed to helping providers thrive. Without that, patients won’t get the care they need.

Can you describe some of the main challenges providers are facing with regard to medical claims?

The next biggest one is authorization. Things need to be pre-certified or authorized. Right now, there is much manual effort between payers and providers to get authorization to get approval. It’s manual, it’s expensive and it’s non-value-add work. Connecting information systems across the chasm can solve it. We haven’t done it yet as an industry.

Why?

It’s really complicated and dynamic. The industry is very fragmented. A provider may have 7-15 different payers, and within those, there are different relationships and parameters for authorization—especially for nonstandard or complex issues. Each contract with a payer carries behavior rules to follow to get authorized and paid. Thousands of practices with different levels of IT sophistication, and IT from different vendors; there are thousands of variants. Payers determine what they believe are acceptable guidelines. They make those rules, and those rules change as medicine and medical payment policy evolve.

With denied claims adding up to approximately $2 billion, what can be done to solve this problem?

Three things:

  1. We have to recognize where incentives or workflows align with payers/providers.

  2. We need to align the systems. We need to understand the pain points and align the information systems around the patients. No one company can do it themselves. We need collaboration between payer/provider and their strategic vendors.

  3. We need to do this in ways where tangible benefits accrue for each side. They need to see results and impact—see operating expenses go down by doing this work; start a virtuous cycle.

Tell us about your work on the Denials IQ solution.

When a claim is sent to a payer, they adjudicate it and determine if they pay some of it, all of it or none of it. They express denial back to the provider in an electronic data set—or remittances. With remittance comes the reason for denial. The reason has a code. Many of those codes were often created 20, 30, 40 years ago. It’s highly cryptic and specific only to that payer in that situation.

Denial codes are like hieroglyphics. It’s difficult to decipher and explain why. Denials IQ has algorithms to turn those codes into English to understand why, when and the root cause that caused the payer to make a denial. That creates appropriate clues for a provider.

What are the potential benefits for patients and health systems?

A customer said to us, “We used to spend 90 percent of our time researching what happened, and 10 percent fixing it. Now we are spending 10 percent researching and 90 percent fixing.” They can take their efforts and apply them to get paid faster with less work. For patients, the benefit is a lot less confusion and fewer patient payment responsibilities. Sometimes when a payment is denied, the provider turns to the patient to get reimbursed. If patients know which services will be covered, there are fewer barriers to getting the appropriate care they need.

With the use of analytics and solutions like Denials IQ, how do you see the future of claims management changing in the next five years?

First, it’s going to have an impact in denials management and operational behavior. We can help take unnecessary expense out of healthcare and drive down the cost of healthcare administration. Second, the system can become smart enough to take output from Denials IQ and change how claims are created to avoid problems in the first place. It creates a self-healing revenue cycle system.

What future effects do you see analytics/big data having on the industry?

Analytics and big data should be applied to create improvements in four main categories: clinical, financial, operational and research. It is a complex ecosystem of life sciences, medical devices, and more. If we could coalesce on a set of important problems to solve, within and across those stakeholders, we can take out unnecessary expense and make healthcare more efficient and quality-oriented to allow us to serve more people, better.

In your own healthcare experiences, are you always analyzing the care experience, or the technology enabling the experience, or can you ever just be “the patient?”

I always watch what they are doing with their systems. I can’t help myself. I’m a healthcare systems solution guy, always assessing what can be done to make our healthcare system more efficient for everyone. The time I’m the best patient is when I’m under full sedation.

Tell us a bit about yourself and your family. Do you have any hobbies or interests you’d like to share?

I’m married with two children and two grandchildren. They continually serve as a source of inspiration and motivation. I’m either blessed or cursed by having what I do be my number one interest. When I’m not here at work, I enjoy outdoor exercise and music. I love listening to guitarists like Frank and Dweezil Zappa, Jeff Beck and Joe Satriani.

What is the best advice you’ve ever received?

About 20 years ago, I was working with a customer. He was a doctor, very brilliant and passionate and knowledgeable—a true delight. I said, “Doc, by doing this, I can bring you all the data.” He grabbed me by the collar and put his face in mine and said, “Jon, I don’t want all the data! You IT guys think it’s good. It floods me and slows me down. Please help me figure out the data that I need, what I need, when I need it, how I need it in a relevant way.”

That moment affected me every day since then. As we bring out our new solutions, I think about serving the doctor in a way that is helpful to them.

What excites you most about your role?

I am using my life experiences to make a difference for other people. I am thrilled to do what we are able to do here, work with customers that I love, my colleagues at GE, and partners to be able to make a difference to make healthcare better. I can’t make people better, but I’m pretty good at systems and people.


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