Bend the administrative curve cost with payment integrity best practices

Health plans transforming their business models to accommodate new markets and new lines of business may experience a strain on their payment integrity programs resulting from fluctuations in membership, business complexities and regulatory mandates across all areas of claims processing. Without a vigorous payment integrity program in place, these pressures can create competing or misaligned objectives across the claims process continuum, in turn leading to more manual interventions and increased provider abrasion and costs.

A well-coordinated, enterprise-wide payment integrity program that identifies both pre- and post-payment claims processing problems, and yields actionable intelligence for systemic improvements, can improve accuracy, lower costs and improve provider satisfaction. Recent industry studies show that payment integrity itself is worth $362 billion in medical cost savings related to improvements and decreases in overpayment.

Best practices for comprehensive payment integrity

There are proven strategies for implementing a payment integrity system that can help plans close claims processing gaps and correct systemic problems:

  • Implement routine self-assessments.
  • Adopt proactive payment procedures.
  • Use service providers.
  • Employ intelligent, integrated analytics and reporting.
  • Take advantage of electronic payments.
  • Perform root cause analysis.
  • Conduct vendor review and consolidation.

It’s important to note that even with these best practices, payment integrity programs need a “champion” at the management level to thrive. This is why appointing an executive sponsor, who can socialize payment integrity initiatives across the organization, is critical to success.

The payoff for plans

Moving away from manual intervention, paper checks and post-pay intervention, and to auto-adjudication, electronic payment and pre-pay claims editing can help plans achieve positive payment integrity results. But transforming business and reducing administrative costs requires modern technology, nimble operating models and advanced analytics. If a plan does not have the expertise or adequate resources in these areas, partnering with a vendor is a viable solution. Doing so allows plans to reduce the complexity and costs of operations and technology.

To read more payment integrity systems and implementation best practices, download our article, “Bend the administrative curve cost with payment integrity best practices.”


About the authors

Donna Holmes, Vice President, Operations Consulting, Optum

Donna Holmes Holmes leads the Operational Consulting and ICD-10 practice at Optum. She brings over 30 years commitment to helping health plans transform themselves through measurable performance improvements. She works with U.S. health plans providing executive leadership in business and IT strategic planning, business performance optimization and organizational alignment to drive higher performance of people, processes and technologies within client organizations.


Erin Schmuker, Client Operations, Optum

Erin_SchmukerSchmuker leads delivery of the Optum Payment Integrity Solutions for Payers. She has more than 15 years of experience in health care payment integrity operations and business development, with 10 years focused on helping payers and providers implement pre- and post-payment integrity programs to drive efficiency and savings. Schmuker works with clients to identify opportunities to implement best practices for payment integrity across the enterprise including software solutions, resource-driven solutions, and full Business Process Outsourcing solutions.

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