The intricacies of payment integrity hold the industry in a perpetual state of adaptation. With data integrity and fiscal responsibility at the forefront, health plans need to manage cost containment efforts by driving down administrative costs and harnessing the power of technology.

With shifting priorities, payers are prioritizing across all lines of businesses to directly reduce and control medical spend as the highest priority over the next two years. Payment integrity is at the top of the list, so they can recover funds that were paid inappropriately while delivering the highest quality of care to members.¹

Power of AI in Payment Integrity

In a recent survey, health plans identified key trends shaping the landscape of payment integrity in 2024:

• Advances in AI and gen AI (42%)
• Complexity of the US healthcare system (21%)
• Financial challenges for payers (21%)
• Increased health spending (16%)

 
These trends underscore the critical role of technology in addressing the complexities and financial pressures faced by health plans. AI, in particular, has emerged as a powerful tool for payment integrity, offering solutions that can quickly identify and prevent inappropriate payments. By leveraging AI, health plans can improve efficiency and accuracy in payment integrity operations while reducing costs.²

One of AI’s key benefits is its ability to rapidly analyze large amounts of data. This allows it to identify patterns and anomalies in claims data that may indicate payment inaccuracy. With traditional manual processes, this would be a time-consuming and labor-intensive task. However, with AI technology, these tasks can be completed in a fraction of the time.

AI can also automate claims selection and extract relevant clinical insights, especially around complex claims reviews, to improve accuracy and operational efficiency. While AI adoption dominates discussions, payers prioritize solutions with proven efficacy and transparency.³

Access to high-quality data is paramount for successful payment integrity programs. However, regulatory uncertainties present significant obstacles to AI implementation.

Shift to Pre-Payment

With 80-85% of technology spending focusing on post-payment methods, there’s a noticeable shift towards pre-payment solutions. A majority of payers (72%) indicate technology investment in a transition to pre-pay models, signaling a move towards proactive identification and prevention of billing discrepancies.²

Pre-payment is a win-win situation between payers and providers. Payers have the opportunity to catch inaccuracies and fraud before claims are paid out, resulting in cost savings and increased payment accuracy. Providers also benefit from an improved revenue cycle management process, as pre-payment methods can help identify and correct billing errors before they lead to claim denials or reimbursement delays.

However, implementing effective pre-payment solutions requires a combination of technology, expertise, and data analytics capabilities. Payers must not only invest in advanced solutions that can detect potential discrepancies but also have the resources and trained staff to review flagged claims effectively. In addition, exchanging data with providers in a timely matter is critical to reducing provider abrasion.³

Despite these challenges, the benefits of pre-payment solutions make it a worthwhile investment for payers looking to improve their payment integrity efforts. By catching errors early on, both payers and providers can avoid costly disputes and maintain positive relationships. Additionally, pre-payment solutions can help identify patterns of fraud and abuse, ultimately improving overall healthcare system integrity.

Balancing Outsourcing and Insourcing Strategies

Provider dissatisfaction and financial constraints further complicate payment integrity efforts, prompting payers to explore both outsourcing and in-house optimization strategies. 16% of payment integrity and cost containment operations are in-house, utilizing manual operations. With 80% outsourcing some portion to a third-party vendor, there are multiple passes across different lines of business/types as well as different functions and processes.¹

This trend of outsourcing and insourcing has been driven by the need for payers to efficiently handle the growing volume of claims while also ensuring accuracy and compliance. By utilizing both methods, payers can leverage the expertise and technology of external vendors while also maintaining control over their payment integrity processes.

However, this approach is not without its challenges. The constant back-and-forth between in-house operations and third-party vendors can lead to communication gaps, which can result in errors or delays in identifying activities. Additionally, outsourcing can be difficult with ‘black box’ decisions that make it challenging to trust fully. You need a strategy to scale by leveraging a blend of technology, process enhancements, and delivering transparent results.

Empowering Payment Integrity Programs with Apixio

As healthcare evolves, it is essential to have the right strategy and partnerships that can scale with demand. This is where Apixio comes in—a leader in end-to-end complex claims solutions. Our platform enables real-time insights and drives efficiency, accuracy, and compliance. With pre- and post-pay solutions, Apixio’s platform is able to handle the evolving changes and provide valuable support to payers looking to streamline their processes while identifying cost savings.

Apixio’s AI and its effective implementation in a unified platform set us apart from the competition. By leveraging advanced technology from OCR to digital extract from documents to identify clinical insights using NLP, our platform enables health plans to accelerate complex claims reviews. Additionally, our technology enables timely reviews by utilizing API integrations and provider portals to enable a shift to pre-pay. Whether you insource or outsource and even want a hybrid approach, Apixio can meet you where you are in your payment integrity journey.

Learn more about Apixio’s payment integrity offerings around complex claims reviews.

¹2023 EY-Parathenon and KLAS Research Payer Tech Study.
²HPRI Payment Integrity State of the Union Report. April 2024.
³KLAS 2023 Payment Accuracy & Integrity Solutions 2023.