Changing Healthcare Payment Integrity in 2023: Trends, Solutions & More

In a recent In90group Research survey of more than 100 health plans, 66% of respondents categorized their payment integrity programs as “enterprise” initiatives with virtually all major departments playing a role in payment integrity. However, the research also revealed that just because multiple departments are involved doesn’t mean they are aligned. In fact, 58% reported that payment integrity initiatives were often at odds with other departments.

 The reasons for this misalignment can be better understood when we consider the fragmented nature of health plans and the technology solutions that support them. Historically, each department acquired solutions to solve their own unique business problems with little-to-no thought around interoperability and data-driven workflows across the enterprise.

Plus, different departments had their own unique goals that sometimes conflict with each other. For example, payment recovery success is typically measured by how much the department is able to recover. Payment integrity success is focused on preventing errors in the first place, which if done properly, will reduce the amount recovered. Network management is often focused on minimizing provider abrasion and is therefore resistant to address over-payments that would support the recovery team’s metrics. 

Aligning departmental incentives and implementing modern, interoperable technology solutions are two critical steps health plans must take to reduce waste, increase savings, and drive better member and provider satisfaction.

A Better Path to Payment Integrity

As the complexities and challenges associated with improving payment integrity continue to rise, now is the time for payers to think differently and implement modern technology that enables an enterprise approach from which all departments can benefit.

When health plans successfully transform their payment integrity initiatives, things like leveraging root-cause analysis of inaccuracies to improve enterprise workflows finally become possible. Reducing dependencies on and costs associated with third-party payment recovery vendors frees resources to focus on more strategic initiatives.

Third-party vendors are challenged to deliver greater value and concentrate on solving more complex issues instead of depending on revenue from the same errors quarter after quarter. Business leaders have the opportunity to analyze more comprehensive payment data to make more informed decisions and compete more effectively.

HealthEdge Source is challenging the traditional approach to payment integrity by empowering health plans with a single platform on which all data can be accessed and leveraged for true payment integrity success.

To learn more about how Source is challenging the status quo and enabling health plans to truly embrace an enterprise approach to payment integrity, visit www.healthedge.com.