Payment integrity (PI) is the process of ensuring a health claim is paid by the responsible party, for eligible members, according to contractual terms and policies, and free of error, duplication, fraud, waste, and abuse. PI addresses both administrative costs and medical expenses – without compromising care. Most plans have PI programs in place, but often they are not optimized and aren’t providing the return on investment (ROI) they could.
Achieving medical claim payment accuracy is difficult for many reasons. Billing is highly complex and requires expertise and conciseness in numerous interrelated areas including regulatory compliance, coding, and staying abreast of the frequent changes in healthcare policies. In addition, some of the needed information may not be digitized or might be highly dispersed, and the challenges become clear.
Focus on an end-to-end strategy
Payment integrity has become an effective tool for managing healthcare costs, but it wasn’t always that way. It started as an operational clean-up function that relied on ‘point solutions’ to address problems one at a time. That approach was a resource-intensive and time-consuming process that produced only marginal results.
Over time, healthcare providers and payers realized the need for a more efficient and effective approach. They began to take a ‘big picture view’ that addressed the full spectrum of the claim payment lifecycle from claim submission to retrospective claim payment review and recovery. New tools were introduced, including advanced analytics that more effectively located errors and anomalies, and new integrated technology platforms were built that enabled automation and streamlining of processes. With an end-to-end strategy becoming the preferred approach, PI vendors broadened and deepened their offerings.
Take a proactive, data-driven approach
For optimal PI outcomes, such as increased claim payment accuracy, reduced costs, and improved operational efficiency, plans with strong PI ROI know that a proactive data-driven approach works best. It enables plans to not only rectify past payment errors but also use those insights to improve their overall payment accuracy efforts going forward.
Applying tools like artificial intelligence and machine learning introduces capabilities beyond traditional rules-based systems. Given the complexity of medical coding, compliance requirements, and specific plan-related provider reimbursement contracts, more sophisticated tools such as these will help associates better implement PI services and drive better results for plans by more efficiently and effectively processing the enormous data sets involved in PI.
Carelon’s Payment Integrity Data Mining Solution leverages sophisticated technology, advanced analytics, and deep expertise to identify billing patterns, trends, and anomalies that cost plans money. Working collaboratively with clients and drawing on learnings derived from decades of experience serving 40 million unique lives, the solution offers the value plans are looking for.
Improve payer and provider relationships
There is an increasing recognition among health plans that payment integrity can be a tool for building stronger relationships between payers and their stakeholders. The way to do that is to foster trust, understanding, and collaboration. A good way to begin is with transparent communication. Opening lines of communication about payment policies, updates, and other changes and hosting ongoing discussions to address concerns and misunderstandings will go a long way toward achieving mutual goals.
When payers and providers can enjoy streamlined processes for claims submission, with reimbursements that are prompt and in accordance with agreed-upon terms, the payer-provider dynamic will change. Payment Integrity programs that invest in provider education programs can help transform the payer-provider relationship into a more collaborative, productive relationship. That can mitigate tension and mistrust and help improve the health of the healthcare system.
Another way to improve relationships is to move payment integrity efforts upstream. Prevention and prepayment interventions help avoid errors before they occur – a more efficient and cost-effective approach. It’s often said that post-payment is good, prepayment is better, and prevention is best.
A world of possibility
The future of payment integrity is promising. Predictive analytics, real-time processing, improved data quality, more automation, interoperability, and the expertise gained with the passage of time will help drive lower healthcare costs and better outcomes. Isn’t that what everyone wants?
Jeff Plante is the president of Carelon Insights, a division within Elevance Health’s Carelon.
