White Paper: Prospective Payment Integrity Moving from Pay and Chase to Predictive
This Spotlight examines payer payment integrity platforms and how payers can aggressively apply analytics and coordinate workflows to move "left" from reactive postpay to proactive, predictive prepay.
Predictive Payment Integrity: Modernizing Payer Operational Systems
The modernization of payer operational systems, particularly in claims editing services and Fraud, Waste, and Abuse (FWA) analytics, is crucial to ensuring accurate claim payments in today's digital transformation era. The overarching goal of payment integrity is to educate providers, prevent poor-quality claims, avoid unnecessary costs, recover improperly spent funds, and shift from postpay to prepay methodologies for better predictive control.
The "pay and chase" method remains prevalent but faces significant challenges such as fragmented processes, systems, organizations, and lines of business (LOBs). There are typically 11 internal departments involved in payment integrity, including Finance, Provider Contracting, and Customer Service. Achieving seamless coordination among these departments requires top-down leadership and breaking down cultural, technical, and organizational silos.
Moving from a postpay to a prepay approach offers substantial benefits, including reducing vendor dependencies, increasing claims reimbursement accuracy, decreasing claim spend, improving claim denial rates, and enhancing both member and provider experiences. However, this shift is not without its challenges, including the difficulty of quantifying the value of education and prevention, and coordinating workflows across different internal organizations.
Key trends shaping the future of predictive payment integrity include the consolidation of internal workflow solutions, the acquisition of externally interoperable solutions, and advancements in claims digitization and adjustment automation. Transparent solutions that offer open API access are essential for centralizing data and enabling informed decision-making.
Enhanced claims processing involves digitizing claims, linking supporting documents, leveraging machine learning for predictive adjudication, and identifying claims likely requiring manual review. Improved Coordination of Benefits (COB) processes and administrative audits further support the integrity of claims processing.
HealthEdge's cloud-based platform, Source, exemplifies how technology can address payment accountability by unifying regulatory data, claims pricing and editing, and real-time analytics. This platform enhances provider relationships, reduces waste, and improves financial performance through advanced integration capabilities.
In conclusion, transitioning from the "pay and chase" method to a proactive prepay approach, supported by advanced AI and machine learning technologies, can significantly enhance predictive payment integrity, reduce costs, and improve overall efficiency in payer organizations.
