By Ryan Mooney, general manager, Source Division, HealthEdge.
In our healthcare ecosystem, waste, fraud and abuse run rampant: in 2020 alone, healthcare spending in the U.S. exceeded $4 trillion, and estimates suggest about a quarter of that was attributed to waste. What this tells us is that an increased focus on payment integrity – and in particular, fixing its traditionally disparate practices – has the potential to greatly benefit payers, providers, and ultimately members.
At its core, payment integrity is the process by which stakeholders ensure healthcare claims are paid properly, both pre- and post-pay. It encompasses determining the correct party, membership eligibility, contractual adherence, and fraud, waste and abuse detection and prevention. In recent years, as healthcare spending continues to skyrocket, payment integrity has received more attention – and investment – than ever. And yet, it leaves much to be desired.
The Current State of Payment Integrity
A comprehensive payment integrity strategy is key to lowering costs and achieving higher quality of care for members, but the systems in place are far from perfect. With over 24 years working in payment integrity, throughout this experience I’ve found it nearly impossible not to run into issues within the system. As it stands, many parties focus on enriching the contingency model versus solving the problem. Structurally, the contingency model is flawed: when the vendor gets paid according to the quantity of errors they find, the core problem will continue, as these parties are incentivized to identify what is incorrect rather than why.
Our 2021 Voice of the Market survey of over 200 health insurance executives found that payment accuracy would help reduce administrative costs at their organization, directly impacting savings that can be reallocated for other business priorities such as considering partnerships, acquisitions, or investing in a new geography or line of business. This represents a substantial shift from the past, demonstrating how stakeholders today want to take advantage of all available resources to expand in the current landscape.