Payer organizations today face significant obstacles as they navigate a new era of member and provider “relationship management.” Members and customers have increased expectations and payers are responding by working towards executing transactions more quickly and identifying incorrect payments and their root causes.
While the spectrum of payment integrity is broad, the goals of all segments are to encourage the affordability of healthcare by preventing poor quality claims upfront, avoiding downstream costs where possible, and recovering improperly spent funds postpay when necessary.
However, trying to achieve these goals is challenging for the average payer organizations due to the following factors:
- Fragmentation within payer organizations requires top-down leadership to break the cultural, technical and organizational silos.
- Quantifying the value of education and prevention is difficult.
- Coordinating workflows across internal organizations is a large challenge.
Moving “left” from postpay to prepay allows payers to have more predictive control and addresses the challenges payer organizations face. While doing so can be organizationally and culturally challenging, there are many benefits and advantages of this shift:
- Increasing accuracy of claims reimbursement and transparency of payments, leading to improved provider relations
- Removing redundant tasks, reducing staff frustration, saving time
- Decreasing claim spend
- Improving claim denial rate
- Reducing the number of claims requiring rework
- Lowering the cost per claim processed
- Reducing the significant claims-related provider inbound call volume
- Improving the member and provider experiences
- Identifying and educating providers by revealing patterns of poor payment integrity practices
An Alternative Approach to Payment Integrity
As the landscape of healthcare payer technologies evolve, an alternative approach to payment integrity is emerging: single, one-stop-shopping solutions. Source, HealthEdge’s payment integrity software, is a single payment integrity solution that offers a centralized repository of data that can be used for multiple functions, such as claims reimbursement, editing, clinical reviews, modeling and analytics. Transitioning to a single-solution system offers payers the opportunity to streamline operations, form authentic vendor partnerships, and take control of a comprehensive approach to their claims payment operations. Learn more about partnering with Source, a transformative, single-solution partner.
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