Payment Integrity Thrives on Clean Data, Provider Buy-In, and Data Visualization Tools

Health plans, like any commercial enterprise, are constantly on a quest for improving their bottom lines by applying the following three strategic levers across their organization: improving operational efficiency, reducing costs, or improving revenue. Hand in hand with these strategic initiatives come their operational siblings―identifying leaks, remedying inaccuracies, and determining inefficiencies―to address and eliminate them. Preventing those leaks or inaccuracies from happening in the first place is ideal. Payment integrity solutions can check off all these boxes, as they impact the core of their business―collecting premiums from enrolled members and paying out claims to healthcare providers.

Over the past 15 months, I researched payment integrity and fraud in claims adjudication by speaking with, interviewing, and surveying special investigation unit representatives, payment integrity leads at health plans, and product leaders at payment integrity vendors. These studies yielded multiple research reports, including a rigorous Aite Matrix evaluation, a comprehensive quantitative report card on payment integrity vendor partners.

If I had to summarize the findings from those studies into one sentence, I’d tell you these three things. You need good data, committed healthcare providers, and cool data visualization to make payment integrity solutions reach their full potential. Let me further unpack this statement.

  • First, the data must be clean, organized, and standardized to be useful. A ton of data pours into a claim adjudication system from disparate healthcare systems, electronic medical records, and independent practitioners. It comes in the form of x-rays, photographs, and written and verbally recorded forms. It comes manually, digitally, the day of or weeks after the date of service. New medical codes associated with telehealth and COVID-19 testing, treatment, and vaccinations add to the varied flavors of data. For any analysis to take place, this data needs to be complete and standardized.
  • Second, providers must be involved and committed in the payment integrity and claims process for payment integrity to function and carry out its promise effectively. Oftentimes, when a question comes up regarding the accuracy of a claim, professional eyes like auditors need to review it. Sometimes the health plan needs to turn to the provider to supply missing information or furnish additional documentation to verify that the line-item charges on the claim are legitimate. Over time, this becomes an irritant in the payer-provider relationship. Payers are acutely aware of the need to preserve those relationships, and so too are vendor partners. Both must secure the provider’s buy-in and win the provider over as a committed partner.
  • Third, and this is what really blew me away, are the powerful data visualization tools that I saw during vendor demos. Visualization is truly the one word that makes all the data crunching, and artificial intelligence, rules engines, and analysis come to life in full color. Looking for irregularities in a provider’s practice? There’s a visual dashboard for that. Looking for trends in a certain geographic region? It is a drop-down menu away. Curious about a patient and provider’s relationship outside of the office? It too is a click or two away. Want to customize, download, and email a specific cut of data? You got it. The power in all this lies under the hood in the AI and in the rules engines and integrations.

Payment integrity vendor partners strengthen health plans, particularly their audit, special investigation unit, or payment integrity departments’ capabilities to further the three strategic levers for health plans, whether it be by identifying the most compelling claims or providers to go after, or by spotting suspicious billing and claim submissions.

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