The administrative side of healthcare where revenue is captured, directly impacting margin, are increasingly run by AI and agents. Finance leaders need context and control to govern this flow.
by Aaron Zavora
Ask a health system CFO where this year's margin is landing and you will always get a hard-won answer, born from the discipline and rigor they bring to the business. And then a list: the case that care cost more to deliver than the health plan will reimburse, the clean claim denied anyway, complex variable payment arrangements that bring unknowns into expected payments, the cash still sitting in receivables on care already delivered.
The aforementioned functions are supported by multiple systems of record. Each is increasingly shaped and made faster and more complex through automation and agents. The mission of finance is to understand the relationships among all variables, bring transparency to medical economics, and to protect the margin for care while setting up the organization to deliver high quality care to patients.
Similarly, health plans face tremendous unknowns. Forecast models and finance functions that cannot quickly adapt to market changes face rising Medical Loss Ratios (MLR), lower reimbursement rates in programs like HEDIS and STARS, and rigid adjudication functions that lack parity with the cost saving techniques and technology.
