Elevating Payment Integrity Through AI Innovation

This report examines the findings from the study that investigated the forces driving payment inaccuracies, the business impact on payers, and the technologies, particularly AI, that are reshaping how leading health plans transition from a reactive payment approach to proactive, scalable payment integrity.

Critical Areas Requiring Immediate Attention

The consequences of payment errors are no longer contained to back-office rework. They ripple across a health plan’s entire operation, creating downstream effects that touch every department. These are some of the impacts of payment inaccuracies:

• Increased operational costs (22%) - Resource drain on strategic initiatives
• Negative member trust impact (21%) - Competitive disadvantage in retention
• Missed revenue targets (19%) - Direct financial performance impact
• Damaged provider relationships (15%) - Network stability risks

Technology Solutions for Proactive Payment Integrity

1. AI-Powered Payment Accuracy

91% of health plans identify AI as a current or near-term priority for payment integrity, yet only 5% have implemented Payment Integrity AI extensively, revealing significant opportunity for competitive advantage through early adoption.

Top AI Implementation Priorities:

• Pre-payment edits (30%)
• Policy/compliance issue detection (28%)
• Fraud and abuse detection (17%)
• Post-payment audits and recoveries (15%)

2. Advanced Analytics and Data-Driven Insights

Making smarter decisions in payment integrity starts with real-time visibility into claims data. Real-time insights bring transparency and allow health plans to monitor claims submissions and adjudications dynamically. Advanced analytics can flag patterns like overbilling, helping health plans address noncompliance before payments are processed. This proactive approach reduces costly post-payment audits and streamlines operations.

3. Prospective Payment Integrity

95% of health plans actively pursue prospective payment integrity, with 73% leveraging pre-payment edits and validations to prevent errors before adjudication. This shift from reactive to proactive approaches delivers:

• Reduced administrative costs - Eliminating time-consuming rework
• Enhanced provider relationships - Minimizing payment disputes
• Improved member satisfaction - Reducing billing confusion and delays

Future-Ready Payment Integrity Strategy

As healthcare innovation continues to accelerate, health plans are looking ahead with a clear sense of both opportunity and urgency. To remain competitive and compliant, they know they must build a foundation for intelligent, proactive payment operations, with AI and modern platforms playing a pivotal role. Here are some actions health plans are taking to prepare:

• Advanced technology investment (23%)
• Enhanced external partnerships (21%)
• Strengthened compliance strategies (21%)
• Specialized personnel development (18%)

With the right technology and enterprise approach, organizations lay the foundation for long-term operational efficiency, cost savings, and a smarter, more proactive claims process that benefits all stakeholders.

Explore our collection of industry research and surveys, offering valuable insights and actionable strategies to help future-proof your health plan.