In the rapidly evolving landscape of healthcare finance, payment integrity has emerged as a critical cornerstone for health plans seeking to optimize operations, reduce costs, and enhance both member and provider relationships. As we stand at the precipice of a new era in payment data and transformation, the traditional paradigms of payment integrity are undergoing a seismic shift. This transformation, driven by cutting-edge technologies, evolving regulatory frameworks, and the shift towards value-based care models, demands a fundamental reimagining of how payers approach business goals, member satisfaction, as well as operational excellence.
Here are five transformative strategies that will not only address current challenges in payment integrity, but also position health plans at the vanguard of innovation in healthcare financial management.
1. Implement a Centralized Payment Integrity Strategy
The era of fragmented approaches to payment integrity needs to be a thing of the past. Health plans must pivot towards a centralized, integrated strategy that encompasses more capabilities along the payment integrity value chain. This approach involves appointing a seasoned leader to oversee a holistic strategy that integrates pre-pay editing, post-pay auditing, and innovation that moves post-pay processes into the pre-pay arena for greater savings and less administrative cost. This centralization will also provide a valuable data collection point. The outpoint will provide views into where payment integrity can better align with goals around provider relations, network adequacy, and value-based arrangements.
For health plans aiming to excel in this new era, establishing single accountability for payment integrity and aligning pre-pay editing strategies with overall health plan goals are crucial. These best practices ensure a cohesive approach to claims management, aligning with the broader objectives of value-based care and patient satisfaction.
2. Harness the Transformative Power of Artificial Intelligence
Artificial Intelligence (AI) and Machine Learning (ML) are no longer futuristic concepts but present-day necessities in payment integrity. These technologies enable near real-time analysis of regulatory documents, proactive identification of high-risk claims, and continuous refinement of claim editing rules. They also have the capability to empower teams to operate more efficiently by removing “the noise” within the data generating more accurate targeting around claim and record review opportunities. Looking ahead, AI-driven contract modeling, cognitive computing for interpreting complex medical policies, and more advanced computing applications for billing patterns, and related anomalies, are on the horizon.
To effectively leverage AI, health plans should establish a dedicated AI/ML task force, develop a phased approach to integration, and invest in robust data infrastructure. This strategic implementation will pave the way for more sophisticated, automated, and accurate payment integrity processes.
3. Innovation in Emerging Clinical Content Areas
AI is revolutionizing pre-pay claim editing by improving contract compliance and ensuring adherence to medical policies. Incorporating specific contract terms into the editing process enhances accuracy by ensuring claims meet negotiated agreements. One example is genetic and infectious disease testing, which demands ongoing innovation in claim editing to address new clinical areas and reduce post-pay corrections.
The number of genetic tests, for instance, has grown by 1650% in the past decade alone. And while comprising less than 1% of healthcare claims, genetic tests often account for 15% or more of medical services that health plans review. The complexity of billing for these tests, with numerous CPT codes leading to payment discrepancies, highlights the need for more streamlined and accurate pre-pay processes. AI has the power to reduce health plan reviews around specialty content such as genetic testing, allowing plans to focus clinical resources on other critical areas to their organization.
4. Elevate the Fundamentals: Data Integrity and Human Expertise
While AI significantly enhances claim processing efficiency and accuracy, it should complement, not replace, key practices like human oversight and analytics. Human expertise remains indispensable for nuanced understanding, critical thinking, and ethical decisions, particularly in overseeing AI operations and handling complex scenarios. Payment integrity fundamentally relies on data quality, necessitating strict data integrity protocols, ongoing staff training, and agility in regulatory adaptation.
To maintain this foundation, health plans should implement strict data integrity protocols and develop comprehensive data management strategies. Simultaneously, they should invest in continuous education for payment integrity professionals, focusing on areas such as healthcare fraud detection, technology utilization, and regulatory compliance. This balanced approach ensures that technological advancements are underpinned by robust data practices, advanced analytics & AI tools, and skilled human oversight—creating a synergy that drives more effective, efficient, and accurate payment integrity process.
5. A Dynamic Pre-Pay Editing Framework
At the core of this strategy lies a comprehensive pre-pay editing solution, featuring a content library on clinical content, payment policies and industry sourced editing developed by experienced medical and coding professionals and sourced from authoritative bodies like the AMA, CMS, and more. The solution must be flexibly to allow for customizations, ease of adoption with the ability to sweep a wide set of claims and claim history. The solution should be supported by the skilled resources that can provide guidance on opportunity, impact and deployment strategies. This foundation enables swift adaptation to new regulations across multiple jurisdictions, preventing improper payments before they occur.
Building on this, secondary editing takes pre-pay editing further by leveraging claims history and expanding review to a broader range of medical claims. This advanced approach, utilizing policy driven content and industry expertise, uncovers additional savings opportunities and drives consistency in claims processing.
As the industry shifts towards value-based care, collaboration between health plans and providers also becomes crucial. By aligning contract terms, sharing data, and jointly addressing billing & coding challenges, plans can ensure compliance while improving accuracy and reducing provider abrasion.
This holistic strategy, integrating comprehensive editing capabilities with greater stakeholder alignment and innovative technologies, enables health plans to navigate the complex regulatory environment while maintaining operational excellence and fostering stronger provider relationships. Ultimately, this approach drives efficiency, reduces costs, and supports high-quality care delivery in an ever-changing healthcare ecosystem.
Conclusion: Charting the Course for Payment Integrity Excellence
As we look to the future of payment integrity, success will hinge on the ability of health plans to embrace innovation while maintaining a steadfast commitment to accuracy, efficiency, and compliance. By leveraging AI, innovating in emerging clinical areas, reinforcing fundamental capabilities, and developing dynamic regulatory frameworks, health plans can position payment integrity as a strategic driver of organizational success.
The journey ahead requires vision, commitment, and a willingness to challenge long-held assumptions. For health plans willing to embrace this transformative approach, the rewards will be significant: reduced costs, improved provider relationships, enhanced member satisfaction, and ultimately, a healthcare system that delivers better outcomes for all stakeholders. The question for health plan leaders is not whether to embark on this journey of transformation, but how quickly and effectively they can lead their organizations into this bold new future.
Mike Spellman
Mike Spellman is Senior Director of Consulting Solutions for Lyric.
