White Paper: A New Paradigm in Payment Integrity - Taking an Enterprise Approach
Gain insights from a survey of health plan leaders on how to solve payment integrity challenges and achieve enterprise alignment.
As the healthcare landscape grows in complexity, health plans face increasing pressure to improve payment accuracy and streamline workflows. However, progress is often hindered by scarce IT resources, outdated technology, and misaligned organizational goals. A recent study commissioned by HealthEdge® Source and conducted by In90group Research surveyed over 100 health plan leaders to uncover the current state of payment integrity and highlight the need for a new, enterprise-wide strategy.
The research reveals that while many health plans view payment integrity as an enterprise responsibility, their traditional reliance on disparate third-party vendors and conflicting departmental incentives prevents them from identifying and resolving the root causes of inaccurate payments. This summary outlines the key findings and provides a path toward a more integrated and effective payment integrity model.
The Current State of Payment Integrity for Health Plans
Traditional approaches to payment integrity are proving insufficient in today's complex payment environment. Health plans are experiencing high levels of inaccurate payments, significant manual resource investment, and competing internal initiatives that limit improvement.
Key Findings from Industry Research
The survey data exposes several critical operational burdens:
- Multiple Third-Party Editors: 90% of health plans depend on two or more payment integrity vendors, leading to multiple datasets, complex update schedules, and an overwhelming IT burden.
- High Claims Rework: 55% of payers report that more than 20% of their claims require rework after the first pass, creating downstream work for provider relations and other teams.
- Growing Resource Demands: 70% of health plans have more than 10 full-time employees (FTEs) dedicated to prospective payment integrity, and 56% expect that number to grow in the next two years.
Top Challenges Hindering Payment Accuracy
The status quo is no longer sustainable. Payers are struggling against systemic challenges that prevent meaningful progress in achieving payment accuracy.
|
Rank |
Challenge |
Percentage of Respondents |
|---|---|---|
|
1 |
Limited resources for fee schedule and policy updates |
64% |
|
2 |
Hiring and retaining qualified payment integrity resources |
58% |
|
3 |
Legacy technology is not flexible enough for unique needs |
56% |
|
4 |
Limited visibility into third-party vendor findings |
43% |
|
5 |
Conflicting departmental initiatives and KPIs |
41% |
|
6 |
Payment integrity is not seen as a priority |
38% |
Shifting to an Enterprise-Wide Payment Integrity Strategy
The research indicates a clear trend toward viewing payment integrity as an enterprise-wide initiative. However, involvement from multiple departments does not guarantee alignment. In fact, 58% of payers feel their organization’s payment integrity goals conflict with other departmental initiatives.
The Problem with Siloed Departmental Initiatives
Different departments often operate with competing goals. For example, a payment recovery team is measured on recovered funds, while a payment integrity team is focused on prospective savings. This creates a KPI conflict that makes it difficult to reduce waste and improve provider satisfaction. Aligning these incentives and implementing modern, interoperable technology are critical steps toward enterprise-wide success.
Top Payment Integrity Goals Through 2025
Health plans are actively seeking a new approach. Their strategic goals reflect a paradigm shift away from reactive recovery and toward proactive, in-house control.
- In-source more payment integrity functionality (59%)
- Derive valuable analytics to drive better business decisions (53%)
- Increase interoperability within the IT ecosystem (53%)
- Reduce operating costs (50%)
- Shift more capabilities upstream to pre-adjudication/pre-pay (50%)
- Reduce dependence on contingency-based vendors (35%)
The Value of a Single, Unified Platform
When asked about a single platform for accessing all pricing and policy edits, 100% of health plan leaders agreed it would be valuable, with 74% stating it would be very valuable. A unified solution directly addresses the most significant challenges payers face today.
Anticipated Benefits of a Centralized Solution
- Reduced Costs and Dependencies: 68% of respondents anticipate reduced costs and less reliance on third-party vendors.
- Greater Visibility: 35% expect to gain greater visibility into the root causes of inaccurate payments.
- Reduced IT Burden: 34% look forward to a reduced burden on internal IT teams.
A Better Path Forward with HealthEdge Source
To successfully transform payment integrity, health plans need a modern technology solution that enables a true enterprise approach. HealthEdge Source is a payment integrity solution engineered to challenge the status quo. It empowers health plans with a single, cloud-based platform where all data can be accessed and leveraged for comprehensive payment accuracy.
By consolidating edits, pricing, and analytics, HealthEdge Source enables organizations to:
- Identify and Resolve Root Causes: Gain the visibility needed to fix systemic payment issues across the enterprise with full platform access.
- Improve Claims Accuracy: Function as an integrated secondary editing solution to enhance accuracy between primary editing and final adjudication.
- Reduce Vendor Dependency: Free up resources from managing multiple vendors to focus on strategic initiatives like fraud, waste, and abuse.
- Drive Informed Decisions: Leverage comprehensive payment data to analyze trends, model changes, and compete more effectively.
By adopting an enterprise approach powered by a unified platform, health plans can finally move beyond reactive measures and build a proactive, efficient, and accurate payment integrity program.
