Stop Recurring Post-Payment Issues with an Open Book Approach to Payment Integrity 

For many health plans, it’s easy to get stuck in a costly cycle of claims rework: pay a claim, spot an error months later, hire a recovery vendor, then repeat. This reactive approach uses unnecessary resources, impacts provider relationships, and reduces efficiency.

Breaking this cycle requires advanced technology and an open-book approach to payment integrity—focusing on transparency, collaboration, and proactive problem-solving.

Examining the Costs of Fixing Errors After Payment

Let’s look at a common scenario faced by health plans. A patient suffers a ski injury and receives multiple diagnostic imaging procedures for their foot and leg. The provider submits a claim with each procedure listed separately. The health plan pays the full amount for each line item and quickly moves on.

Months later, during a routine post-payment review, the health plan discovers the system didn’t apply the Multiple Procedure Payment Reduction (MPPR) rule. As a result, there’s an overpayment of $295.75 on that single claim. This “small” mistake adds up when multiplied across thousands of claims.

Now, the health plan must hire a recovery vendor to chase down the overpayment. But these vendors typically recoup only 50-60% of lost funds, and charge a percentage fee based on the recovered amount. That means a significant portion of the overpaid amount is never returned to the health plan.

Claims recovery also contributes to increased administrative burden. Health plan teams must verify the vendor’s findings, notify the providers, negotiate repayment, and reprocess claims. Providers, in turn, must spend additional time adjusting claims and appealing disputed recoveries. These negative experiences can result in provider abrasion, potentially reducing provider willingness to work with your health plan and impacting member satisfaction.

On an individual basis, these cases may seem minor. But on a larger scale, repeated errors drain budgets and operational bandwidth. Taking an open-book approach promotes collaboration with providers, increases transparency in claims processing, and reduces the risk of disputes or overpayments.

Enhance Initial Claims Accuracy with HealthEdge Source™

The HealthEdge Source payment integrity solution transforms claims processing by helping stop inaccuracies at their source. Traditional technologies handle claims step-by-step, starting with pricing and then moving to editing. This handoff between steps is where errors often slip through. HealthEdge Source takes a more integrated approach using parallel processing. This means that all claim rules, policy edits, pricing checks, and reimbursement calculations happen in the same step for enhanced control and accuracy.

Let’s revisit the ski injury scenario. With parallel processing, HealthEdge Source reviews the claim, applies MPPR edits, recalculates payments, and adjusts for secondary procedures in real time. If there’s a discrepancy or a potential overpayment, it’s caught before the claim is finalized. Instead of waiting months to uncover mistakes, the plan and provider receive timely, accurate payment information.

The operational benefits are immediate:

• By stopping overpayments before they happen, health plans avoid losing money to errors and recovery vendor fees.
• Internal teams are freed from managing vendor contracts, auditing claims, and reprocessing payments.
• Enhanced accuracy cuts down on disputed claims while fostering provider trust.
• This approach easily adapts to growing claim volumes and regulatory changes, future-proofing payment operations.

Access Real-Time Claims Editing

Healthcare is getting more complex. Errors will only grow costlier if left unchecked. Stopping them before they start saves money, frees resources, and puts you ahead of regulatory changes.

An open-book strategy encourages cost and pricing transparency to help eliminate unnecessary spending. By adopting an open-book approach to payment integrity with advanced technology like HealthEdge Source, health plans can stop overpayments, improve transparency, and strengthen provider relationships. This allows teams to focus on member satisfaction and growth instead of backtracking. Break the pay-and-chase cycle and make integrity the standard for your team.

“If people change the way they think about payment integrity, it will start to inspire people to work on improving the system.” – Ryan Mooney, HealthEdge Chief Product Officer

Discover how Platform Access from HealthEdge Source makes it possible for health plans to gain more control of the claim process and streamline edit configurations to save time and reduce hassle. Watch the webinar on-demand: Edit Smart Not Harder with HealthEdge Source™