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New Research Results: Top 5 Trends in Payment Integrity for Health Plans

In90group Research recently hosted a webinar with AHIP and HealthEdge to release findings from a new study of more than 100 health plan leaders regarding the current state of payment integrity and how health plans are approaching their payment integrity strategies for 2025.

Based on the data, it appears that health plans should consider a fresh approach to payment integrity across their enterprise to help tackle some of their long-standing and most frustrating challenges. The highly interactive webinar featured Ryan Mooney, EVP and GM, HealthEdge Source and Carl Anderson, Carl Anderson, Senior Product Manager HealthEdge Source sharing their perspectives on the data.

To watch the full webinar, click here: New Research In Payment Integrity Reveals a Paradigm Shift is Underway.

We’ve summarized the five key findings in this post.

5 Take-Aways From the New Research

  1. Workforce Shortages and Limited Resources: A significant challenge faced by payer organizations is the limited availability of qualified resources to ensure accurate claims payment. The webinar revealed that 64% of respondents ranked limited resources as one of their top issues, preventing them from keeping up with changing fee schedules and policy updates. Additionally, 58% expressed difficulty in hiring and retaining qualified professionals for this complex work. These challenges may arise due to the manual labor involved in ensuring accurate claim payments.
  2. Limited Visibility and Root Cause Issues: Another prominent challenge identified by payers is the limited visibility into third-party vendors and root cause issues. Without comprehensive visibility, payers struggle to identify the underlying causes of payment errors and address them effectively. This lack of insight leads to a cascade of problems, such as increasing workload and growing financial losses. Achieving transparency and identifying root causes are crucial for building effective payment integrity programs.
  3. Manual Rework and Costly Errors: More than half of the respondents revealed that over 20% of their claims required rework, which incurs significant costs ranging from $25 to $181 per claim. The financial burden resulting from these errors extends beyond rework expenses and includes factors like provider dissatisfaction and member dissatisfaction. To address this issue, payers need to focus on getting claims right on the first attempt.
  4. Misaligned Initiatives: While payment integrity initiatives involve multiple departments within an organization, misalignment often hinders their effectiveness. The webinar findings indicated that over half of the respondents felt that their organization’s payment integrity initiatives were at odds with other initiatives. This misalignment can be attributed to a lack of a common goal across departments, competing priorities, and stretched resources. Achieving a more holistic enterprise approach is vital for overcoming these challenges and ensuring a unified payment integrity program.
  5. Misaligned Vendor Incentives: Many payers struggle with the burden of multiple third-party vendors, resulting in increased costs and complexities. In the webinar, the speakers highlighted the challenges faced by payers when using several editing tools stacked on top of each other. These challenges include maintaining multiple IT systems, managing conflicting content, and navigating fragmented workflows. Consolidating vendor relationships and adopting a single, unified platform can help reduce costs, streamline operations, and enhance efficiency.

The Path Forward: Technology as a Solution

Historically, technology has taken a backseat to content when it comes to selecting payment integrity vendors. However, the webinar highlighted a shift in focus, with technology emerging as a critical component in overcoming payment integrity challenges. Payers are realizing that technology can provide solutions and streamline processes that manual labor alone cannot achieve. By leveraging modern and flexible technology, payers can effectively tackle rising complexities and improve their payment integrity initiatives.

To address the challenges identified in the webinar, HealthEdge Source delivers a modern technology platform that gives payers the ability to access pricing and policy changes from a single place, thereby improving transparency and streamlining operations. By leveraging technology, payers can achieve greater control, visibility, and interoperability within their payment integrity initiatives. Additionally, technology empowers payers to reduce dependency on contingency vendors and address root cause issues, resulting in improved accuracy and savings.

To learn more about how Source can help your organization achieve its payment integrity goals, visit Prospective Payment Integrity – HealthEdge.


About the Author

Jared has been working in the payer reimbursement and payment integrity sphere for around two decades. As chief strategy officer at HealthEdge Source, Jared continues to work closely with health plans to understand their unique challenges and deliver solutions that can achieve their long-term goals.

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