Payment Integrity: Exceeding Expectations
- With healthcare utilization and per-unit costs continuing to increase, health plans are intensifying their payment integrity programs.
- Payment integrity programs are vital for health plans to stay competitive and protect members.
- A mid-sized health plan with nearly 500,000 members uses payment policy management for automated claim editing and coding validation for complex claims.
Combat rising healthcare costs with robust payment integrity programs. Health plans are actively minimizing inappropriate payments through prepay, postpay analyses, and data mining, thereby protecting member benefits. These strategies,from automated claim editing to coordination of benefits validation,are key for achieving meaningful cost savings. News Directory 3 highlights how various health plans are innovating to reduce improper payments.Discover what’s next in payment integrity.
Health Plans Tighten Payment Integrity Programs for Cost Savings
Updated may 30, 2025
With healthcare utilization and per-unit costs continuing to increase, health plans are intensifying their payment integrity programs. These programs aim to minimize inappropriate payments while safeguarding plan benefits for members. The efforts span from automated prepay editing of standard payment scenarios to in-depth postpay analysis of complex medical pharmacy concepts.
Payment integrity programs are vital for health plans to stay competitive and protect members. Here are examples of how diffrent sized health plans are working to improve payment accuracy and reduce costs.
Mid-sized health plan: Prioritizing prepay integrity
A mid-sized health plan with nearly 500,000 members uses payment policy management for automated claim editing and coding validation for complex claims. This approach has reduced medical costs by more than 3.5% by decreasing improper payments across Medicare Advantage and commercial lines of business.
Regional Blue Plan: Deploying data mining
One regional Blue Plan has adopted an incremental approach to its data mining program. By adding new medical pharmacy concepts, such as pharmacy benefit manager duplicates and Rx provider outreach, the plan has recovered over $64 million in overpayments. This customizable, dynamic libary of concepts delivers better results for the plan’s members through increased recovery of inappropriate payments.
Large national payer: Validating coordination of benefits (COB)
A large national payer implemented a “pause-and-review” approach using a prepay COB validation solution to prevent inappropriate payments. After initial success, the client expanded the program to several other states. This robust prepay-to-postpay feedback loop has enabled the client to realize more than 99% of identifications as cost savings achieved by preventing inappropriate payments.
Cotiviti was recently designated the highest in the Leader Category by Everest Group in the Payment Integrity Solutions PEAK Matrix® Assessment 2025. The report reflects continuous innovation, commitment to accuracy, and proven success in delivering value to clients.
What’s next
Health plans will likely continue to refine their payment integrity programs, leveraging advanced technologies and data analytics to identify and prevent inappropriate payments. Collaboration and innovation will be crucial for achieving further cost savings and ensuring members receive the full benefits of their plans.