U.S. Health Insurance: Payment Integrity and Fraud in Claim Adjudication

A new Aite Group report finds that Technology tools can help health plans review claims and ensure accurate payments to healthcare providers.

Boston, July 16, 2020  — Healthcare payers are under pressure to control costs, and payment integrity plays an important role in those efforts. Verifying the validity of claims is a daunting task, however, and identifying fraud, waste, and abuse is only becoming more complex. Fortunately, technology for payment integrity is evolving. The latest Aite Group report, U.S. Health Insurance: Payment Integrity and Fraud in Claim Adjudication, explores the technology tools that can help health plans review claims and ensure accurate payments to healthcare providers.

“If health plans could wave a magic wand over their claims processing workflows, they would wish for real-time claims processing, increased accuracy, the ability to use automated tools to request medical records, and dashboards that provide a real-time or near-real-time view of the claims process and inherent risks,” explains Inci Kaya, senior analyst at Aite Group.

This report analyzes the current and future state in payment integrity and in the underlying claims processing workflow. Based on interviews that Aite Group conducted between Q4 2019 and Q2 2020 with 36 executives from payment integrity, payment accuracy, fraud, claims processing, and identity verification vendors as well as U.S. health plan executives, it presents insights on health plans’ position on payment integrity and reveals what they want from their technology vendor partners.

To request a press copy of this report or to speak with Inci Kaya about this topic, please contact us at [email protected].

About Aite Group:
Aite Group is a global research and advisory firm delivering comprehensive, actionable advice on business, technology, and regulatory issues and their impact on the financial services industry. With expertise in banking, payments, insurance, wealth management, and the capital markets, we guide financial institutions, technology providers, and consulting firms worldwide. We partner with our clients, revealing their blind spots and delivering insights to make their businesses smarter and stronger. Visit us on the web and connect with us on Twitter and LinkedIn.

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