Written by xScion
on July 27, 2018


Improper claims payment contributes more than $200 billion to the annual cost of U.S. healthcare, yet few payers are leveraging modern techniques and tools to proactively curb these unnecessary costs.

If this sounds like your organization, it may be time for a payment integrity revival. According to a report from Gartner, “2018 is ripe for a payment integrity renaissance”. Traditionally, many health payers employ multiple payment integrity vendors and solutions, each supporting a different business unit or targeting a specific use case (e.g. duplicate claims, subrogation, coordination of benefits, auditable claims and claims with missing data). This is called a stacking approach, which costs more to purchase and maintain over time, often resulting in similar or redundant services being provided across the organization. If cost containment is at the top of your mind, it is worth a review of payment integrity vendors and solutions from the enterprise perspective.


Top 5 Considerations for Evaluating Payment Integrity Solutions

  1. Determine the value of current payment integrity approaches across individual business units and across the enterprise. This involves engaging stakeholders across multiple business units and understanding specific and related problems they are trying to resolve.
  1. Perform and in-depth ROI analysis to uncover the true costs and value offered by each vendor as it relates to each business problem. Do your vendors have healthcare domain expertise, a mature model for data and advanced analytics, and proven, measurable results in improving the accuracy of claims payments?
  1. Evaluate payment integrity vendor capabilities and align them with your individual business objectives and business problems. What are your vendors core competencies in retrospective, prospective and preemptive solutions that address areas such as clinical code editing, other party liability, coordination of benefits, high dollar claims audits and missing provider data?
  1. Ensure that the vendor you choose has pre-claims payment prospective and preemptive techniques, in addition to traditional retrospective approaches. Avoiding the pay and chase model is a strategic imperative to achieving increased profitability and productivity.
  1. Identify opportunities to streamline payment integrity capabilities by consolidating the tools and techniques used to tackle erroneous payments.

“But, My Business Doesn’t Have the Resources or Time to Evaluate My Payment Integrity Solutions, Even Though Cost Containment is a Top Objective of My Performance This Year.”

This is a common challenge for payers as the root causes of improper payments are varied as are the solutions. This is where an experienced vendor with deep domain knowledge and expertise in new, advanced analytic techniques and machine learning can provide real value and insights to inform enterprise decision making.