Infographic: The Changing State of Payment Integrity for Health Plans

The current state of payment integrity reveals significant challenges and complexities that health plans must urgently address to meet member demands for greater transparency. Recent research has identified key barriers to progress in payment integrity improvement, with misalignment of vendor incentives and departmental objectives being central issues.

Current Landscape and Challenges

Payment integrity is critical for health plans aiming to improve payment accuracy, streamline workflows, minimize downstream work, and enhance member satisfaction. However, the industry faces several pressing challenges:

• Vendor Reliance: 90% of payers use multiple third-party editors to ensure payment accuracy.
• Rework Rates: Over half of payers need to rework more than 20% of their claims due to initial inaccuracies.
• Resource Allocation: 70% of payers have more than 10 full-time equivalent (FTE) employees dedicated to payment integrity, with nearly half employing over 25 FTEs.
• Workforce Expansion: 56% of payers anticipate the need to grow their payment integrity teams within the next two years.

Key Barriers to Improvement

Efforts to enhance payment integrity are hampered by several significant obstacles:

• Limited Resources to keep pace with changing fee schedules and policy updates.
• Hiring Challenges in attracting and retaining qualified personnel for complex tasks.
• Visibility Issues in third-party vendor operations, hindering root-cause problem resolution.
• Outdated Technology lacking the flexibility to meet evolving requirements.
• Conflicting Objectives between departments and performance metrics.

Vendor Frustrations

Common frustrations with current payment recovery vendors include:

• High costs (58%)
• Lack of innovation and upgrades (47%)
• Limited savings and value (37%)
• Inefficiency in achieving results (32%)
• Limited content (27%)
• Poor customer service (22%)
• Lack of transparency (21%)

Moving Forward

To overcome these challenges and improve payment integrity, health plans should:

• Align departmental objectives to prevent errors before claims are paid.
• Implement modern, interoperable solutions.
• Adopt an enterprise-wide approach to payment integrity.

Conclusion

Discover how HealthEdge Source can assist your organization in taking a fresh and effective approach to payment integrity. Download the full "Trends in Payment Integrity" research report from our website to gain comprehensive insights on the state of payment integrity.

For more information, visit the HealthEdge Source page or contact us at [email protected].