Virtual Card Rails Beyond Claims: Where Healthcare Payments Actually Want to Be Automated
Abstract
Virtual cards have penetrated healthcare through claim-based payments, but this represents the most conservative and politically constrained insertion point available. The real opportunity lies in payment workflows where clinical regulation is absent, multi-party reconciliation is manual, and treasury sophistication is low. This analysis examines three higher-leverage domains: bundled episode payments with their inherent disaggregation complexity, post-acute and value-based care enablement where cash flow trumps unit economics, and employer-direct arrangements where payers actively want intermediation. The thesis is that virtual cards become genuine infrastructure rather than interchange arbitrage when inserted at points where payment logic itself creates switching costs. Bundled payment conveners, particularly consulting firms that design episode models but don’t control disbursement, represent an underexploited wedge into sticky, high-margin payment orchestration.
Table of Contents
Why Claims Are Actually the Wrong Reference Point
Bundled Payments as Structural Card Territory
The Hayes Opportunity and Convener Economics
Post-Acute: Better Margins, Less Political Heat
Value-Based Care Platforms That Don’t Want to Touch Money
Employer-Direct and the Interchange Blindspot
Patient-Mediated Payments With Embedded Controls
What Actually Creates Moats in Healthcare Payment Rails
Why Claims Are Actually the Wrong Reference Point
Optum runs virtual cards through claim payments because volume justifies the build and providers already expect remittance bundled with payment. The pitch is administrative simplification, which blunts pushback on interchange fees that would otherwise trigger provider revolts. But claims also come with baggage that caps both economics and design flexibility. They’re price-regulated through fee schedules, audited by states and CMS, politically visible when margins look extractive, and deeply embedded in existing clearinghouse and remittance infrastructure that took decades to stabilize. The result is that virtual card penetration in claims looks more like a tax on existing rails than actual innovation in payment architecture.
The better hunting ground is off-claims entirely, where payments are operational instead of clinical, margin opacity is higher, and nobody has entrenched opinions about how money should move. These are environments where cards can encode business logic instead of just replacing ACH. The pattern to look for is fragmented payables with weak treasury operations and tolerance for fees that stay invisible to end buyers. Healthcare has more of this surface area than almost any other sector, but most of it sits outside the claim flow that gets all the attention.
Bundled Payments as Structural Card Territory
Bundled payments get talked about as a Medicare innovation play or risk-sharing mechanism, but they’re actually a structural opportunity for payment infrastructure because disaggregation is inherently painful. A typical episode bundle involves a single lump sum payment to a convener, which then has to split funds across the hospital, multiple physician groups, anesthesia, post-acute facilities, durable medical equipment suppliers, sometimes imaging or lab vendors, and occasionally home health or rehab services. Each downstream participant has different contract terms, different performance metrics, sometimes different risk arrangements. The disaggregation process today is almost entirely manual, driven by spreadsheets and contract PDFs, reconciled weeks or months after the episode closes, and paid out through a mix of ACH transfers and actual paper checks in some markets.
Virtual cards let you collapse that entire operational mess into programmable payment logic. You can time-gate disbursements based on outcomes windows, like holding back surgeon bonuses until ninety-day readmission data clears. You can encode episode-specific rules directly into card controls, so post-acute payments only release after acute discharge documentation hits the system. Remittance metadata flows with the payment instead of requiring separate reconciliation, which matters enormously when you’re splitting a single bundle check across eight different entities with different EINs and different GL codes. And you can apply merchant fees per downstream participant without the convener needing to negotiate or track those costs separately. ACH cannot do any of this without custom middleware that somebody has to build and maintain, which is why most bundled payment programs still run on spreadsheets and monthly reconciliation calls.
The Hayes Opportunity and Convener Economics
Hayes Management Consulting sits in a weird but lucrative position in the bundle ecosystem. They design the clinical pathways, define the gainsharing formulas, build the actuarial models that determine how much risk each party takes, and often manage the ongoing performance reporting. What they typically don’t do is own the actual payment rails. Money flows from the payer to some designated convener, then that convener manually distributes funds based on whatever contract Hayes helped design. There’s a gap between program design and payment execution, and that gap represents uncaptured economics.
A Hayes-anchored payment platform would look like this: Hayes or a joint venture becomes the actual payment orchestrator, not just the consultant. Bundle funds flow into a controlled treasury account that Hayes operates. Downstream distributions happen via virtual cards issued directly to participating providers. Hayes earns their existing program fees for clinical design, but now also captures merchant processing fees on every disbursement, plus potential float value from timing differences between when the payer funds the bundle and when downstream participants get paid. This reframes Hayes from risk consultant to payments infrastructure with embedded clinical logic, which is a completely different business model with completely different margin potential.
Could they own the whole market? No, because bundled payments remain a small fraction of total healthcare spend and the programs themselves are bespoke by design. But they could absolutely dominate their existing client base because bundles have massive switching costs once clinical workflows and contract terms get operationalized. Payment logic becomes tightly coupled to episode design, which means changing payment vendors requires renegotiating the entire bundle structure. This looks more like vertical SaaS economics than fintech scale plays, but gross margins can hit seventy or eighty percent if the platform is the only thing that knows how to execute the payment waterfall correctly.
Post-Acute: Better Margins, Less Political Heat
Post-acute care is where bundled payment theory crashes into operational reality, and it’s also where virtual cards have better product-market fit than anywhere else in the acute episode. Skilled nursing facilities, home health agencies, and rehab providers are fragmented, undercapitalized, running on thin margins, and almost universally bad at revenue cycle management. They get paid slowly, have limited access to working capital, and often lack the treasury infrastructure to optimize payment terms. They’ll accept interchange fees if it means getting paid faster with clear remittance, because cash flow is worth more than rate optimization when you’re operating on fifteen percent margins.
Use cases are straightforward but high-volume: per diem payments to SNFs that participate in bundled episodes, visit-based payments to home health agencies, episode-based disbursements to outpatient rehab facilities. The pain point isn’t complexity of payment logic, it’s speed and clarity. Most post-acute providers are still waiting thirty to sixty days for bundle reconciliation, then another two weeks for ACH settlement, then manually matching remittance advice to their billing system. Virtual cards can cut that entire cycle to same-day settlement with embedded remittance metadata, which is genuinely valuable to providers even after interchange.
This is arguably a better insertion point than acute bundles because acute hospitals have leverage and sophistication. They can push back on interchange, they have treasury teams that optimize payment terms, and they’re politically connected enough to make noise if fees look extractive. Post-acute providers have none of those advantages, which makes them both more willing to accept cards and less able to extract concessions on pricing. The total addressable market is smaller than acute care, but margin realization is much higher and regulatory scrutiny is much lower.
Value-Based Care Platforms That Don’t Want to Touch Money
The value-based care enablement layer is full of companies that are good at clinical coordination or quality reporting but terrible at financial operations. These are care management vendors that help primary care groups hit quality benchmarks, remote patient monitoring platforms that generate savings through hospital avoidance, quality reporting firms that manage HEDIS and Stars submissions, and various flavors of enablement software that coordinate MSSP or direct contracting arrangements. They all have the same structural problem: they receive performance-based revenue that’s contingent on shared savings or quality bonuses, then have to distribute portions of that revenue to downstream provider groups based on contribution models nobody really agrees on.
Most of these vendors have no interest in becoming payment processors, but they end up doing it anyway through manual ACH transfers and reconciliation spreadsheets because nobody else wants to own the problem. Virtual cards let them become the financial hub without building actual treasury infrastructure. Funds flow into the platform, disbursements happen via virtual cards with embedded attribution logic, and the platform earns interchange while staying completely out of regulated claim flows. This is especially powerful in MSSP-adjacent programs where clinical entities want to participate in upside without becoming an ACO themselves, because the enablement vendor can own the money movement without touching clinical decision-making.
The wedge here is that these platforms already own the reporting that determines who gets paid what. Adding payment execution is a natural extension that generates economics without requiring the platform to take on balance sheet risk or regulatory burden. It’s pure margin expansion on an existing customer relationship, which is why the opportunity keeps getting overlooked by fintech companies that want to build horizontal payment rails instead of embedding into vertical workflows.
Employer-Direct and the Interchange Blindspot
Employer-direct contracting is the one corner of healthcare where buyers genuinely do not care about interchange fees, which makes it nearly perfect territory for virtual card insertion. When a self-insured employer contracts directly with a center of excellence for bariatric surgery or orthopedic bundles, the payment workflow involves the employer or their TPA sending a lump sum for the case rate, then some intermediary managing execution and paying downstream providers. Speed and reporting matter, unit cost optimization does not, because the employer is already getting a discount versus network rates and cares way more about predictability than basis points on payment processing.
Virtual cards work in this context because employers want control and visibility, TPAs want to avoid building payments infrastructure, and providers want fast settlement. The employer doesn’t see interchange as a cost because it’s embedded in the program fee, the TPA earns margin by offering a differentiated service, and the provider gets paid faster than they would through traditional claim cycles. Nobody in the transaction has an incentive to optimize away the card, which is completely different from payer-driven models where providers have enough volume to demand better terms.
This is greenfield compared to traditional payer claims because the number of transactions is lower but the margin per transaction is higher, and there’s no political sensitivity around whether payment rails are extractive. Employer-direct is also growing faster than people realize, particularly in surgical bundles and specialty drug management, which means the TAM is expanding while legacy infrastructure is still mostly absent. The challenge is distribution, because you need relationships with benefits consultants and TPAs rather than provider networks, but the economics are cleaner once you’re in.
Patient-Mediated Payments With Embedded Controls
This one is more controversial but potentially higher margin: virtual cards issued to patients for specific healthcare spending with encoded restrictions on what they can buy. Fertility benefits are the clearest example, where employers or insurers provide a fixed subsidy for IVF or egg freezing, and patients need to coordinate payments across multiple providers for procedures, medications, monitoring, and lab work. The traditional model is reimbursement, where patients pay out of pocket and submit receipts, which is administratively painful and creates cash flow problems for patients who don’t have the liquidity to float thousands of dollars.
Virtual cards solve this by giving the patient a spending instrument with embedded controls: it only works at approved fertility clinics and pharmacies, it can have procedure-specific spending limits, it generates automatic documentation for the plan sponsor, and it completely eliminates reimbursement workflows. The same model applies to specialty pharmacy copay assistance, travel and lodging benefits for centers of excellence programs, and various consumer-directed health benefits that employers are trying to offer without building claims infrastructure.
The economics here are interesting because patients don’t push back on interchange, plan sponsors value fraud reduction over cost optimization, and providers are willing to accept cards if it means guaranteed payment instead of chasing patient collections. This is already happening in benefits administration tech, but healthcare-specific players are underutilizing it because they’re stuck thinking about cards as a replacement for claim payments rather than as a patient spending control mechanism. The regulatory question is whether these arrangements trigger any Medicaid or Medicare kickback concerns, which they generally don’t as long as the benefit is structured as a plan feature rather than a provider inducement, but that requires actual legal architecture.
What Actually Creates Moats in Healthcare Payment Rails
The strategic pattern across all these insertion points is that virtual cards work best when payments are multi-party, logic is contractual rather than clinical, cash flow matters more than unit economics, and nobody wants to build the infrastructure themselves. Claims fail most of these tests, which is why Optum’s implementation looks more like interchange arbitrage than genuine platform defensibility. The places where cards actually create moats are where payment logic itself becomes the product, not just the rails.
Bundled payments have this property because the disaggregation rules are specific to each episode design, which means switching payment vendors requires re-implementing business logic that’s tightly coupled to clinical workflows. Post-acute has it because speed and clarity are worth more than rate optimization, which means providers will tolerate interchange to solve cash flow problems. Value-based care enablement has it because the platform already owns the performance reporting that determines payments, so adding disbursement is margin expansion on an existing sticky relationship. Employer-direct has it because buyers don’t care about interchange and want control more than cost reduction. Patient-mediated benefits have it because spending controls are the actual product, not just a payment method.
The common thread is that all of these are environments where somebody already owns the relationship or the data or the contract structure that determines how money should move, but they don’t own the actual money movement. That gap is where card economics hide best, because you’re not competing on price, you’re competing on whether the buyer wants to build the operational complexity themselves. In most cases they don’t, which means the willingness to pay is high even if the absolute dollar volume is lower than claims.
The next question is which actors in these spaces are positioned to own the episode or the program but currently don’t own the treasury function. Bundled payment conveners like Hayes are the obvious example, but there are equivalent players in every vertical: care management platforms in MSSP, benefits administrators in employer-direct, patient navigation companies in centers of excellence programs. The ones that figure out how to embed payment logic into their existing product will capture margin that currently leaks to generic ACH infrastructure or gets lost in manual reconciliation. The ones that don’t will keep running on spreadsheets while somebody else builds the rails underneath them.