Ask the expert: Why consider comprehensive payment integrity?

By: Steve Yurjevich, Vice President and General Manager, Payment Integrity, Optum

This is the 1st blog of our 3 part series “Uncover hidden funds with comprehensive payment integrity

Where do you find the resources to fuel your strategic objectives? What if a more holistic approach to payment integrity could reduce your medical spend, reduce administrative expenses and improve your claims payment accuracy? Increasingly, payers are using a comprehensive payment integrity model to achieve their growing medical expense savings targets. The key is to have a centralized center-of-excellence (COE) management model that includes payment integrity functions from pre-payment and even pre-adjudication cost avoidance components to your post-payment recovery efforts.

This blog series explores how a strong, comprehensive payment integrity strategy can yield significant results to further fund your strategic objectives.

What is comprehensive payment integrity?

Traditionally, payment integrity efforts have focused on post-payment recovery. In contrast, a comprehensive approach deploys analytics and strategies that encompass every step from pre-claim avoidance to post-payment.

Most payers are seeing excellent results with their post-payment efforts. It’s a proven model to recoup funds to fuel growth and expansion. But over the past 10 years, the evolution of analytics and predictive modeling have enabled an even more sophisticated strategy. This is driven by demand from the Centers for Medicare and Medicaid Services (CMS) on a state level. In fact, for the past decade, state governments have used this advanced model to drive down expense and increase revenue. Now commercial payers are recognizing the dramatic advantage comprehensive payment integrity delivers.

Are you talking about auditing our high-dollar claims before they are paid?

That is an element of prepay, but only one of them. Comprehensive payment integrity spans all of the following opportunities for cost savings:

What are the benefits of comprehensive payment integrity?

There are two key success levers: The first is net new incremental savings. You are still containing costs via post-pay recovery. But now you are also identifying problematic claims before they reach payment to avoid incurring those costs altogether. With post-payment, you lose 20–30 cents on every dollar you recover. With pre-payment, you yield 100%. And if you are working with one trusted partner responsible for oversight of the whole payment integrity process, that partner is incented to achieve the most possible returns for you, which mitigates the detection cost. This comprehensive partnership is an important element of this approach.

The second lever is administrative savings gained by breaking down silos and combining your various payment integrity assets into one department. Typically a health plan has 12–25 payment integrity partners. Each is focused — and compensated — for a particular niche in the payment stream. That siloed approach is limited in the results that can be achieved. However, if one of the partners were responsible for overseeing the entire payment integrity process, you can yield exponentially greater results from that synergy.

What cost savings can we achieve with comprehensive payment integrity?

At Optum, we regularly see a 1–2 % increase in medical expense cost savings. That’s new incremental dollars and also administrative cost savings. What could that fuel for you? It could mean $100 million in potential annual savings with no layoffs, no cutbacks. Just by tightening the claims stream and approaching your payment integrity department in a new manner.

Won’t providers be resistant to any abrasion pre-payment tactics may create?

You’d be surprised to learn how many of your providers are already collaborating with health plans on pre-payment activities. They recognize the accountability needed to comply with state, federal and payer-specific policies. Additionally, providers would much rather be paid correctly the first time than be paid by a health plan and then to find out weeks or months later that the health plan paid incorrectly and now wants some of their payment returned.

What should I do first if I want to expand my payment integrity into pre-pay?

Learn more about what a comprehensive model can do for your plan and gain internal support for it. Ultimately, you will need to organize your internal payment integrity assets under one leader who reports into the CEO. This kind of realignment can be stressful to an organization. But as noted earlier, just as siloed vendors limit your results, a siloed internal payment integrity structure also impedes your success and savings potential.

Why is Optum so advanced in comprehensive payment integrity?

We’ve been working with CMS for more than 10 years to develop the algorithms and analytics to create the predictive models that the state governments are using. At Optum, we now bring those significant medical expense cost savings to payers like you through a comprehensive strategy to identify and recover inappropriate claim payments and overpayments, and reduce administrative costs. What’s more, Optum has been operating a comprehensive payment integrity model for our health plan clients for the last 15 years. We manage payment integrity for more than 100 million lives today. And when this model is fully utilized, it can help health plans save upwards of 8–10% of their total medical expense annually through payment integrity functions.1 We have proven through experience how this model drives additional savings.

1. For a 4,000,000 member health plan on the East Coast, our assessment process found an annual medical expense savings opportunity over $130M.

Learn more in this blog series and the resources below.



Request an assessment

See how simple and intuitive the process would be for your organization.

Watch the video

Vital steps to optimizing payment integrity

Connect with Optum to evaluate what value comprehensive payment integrity can deliver for you

What is your percentage of medical expense savings for your organization through your payment integrity services? 


About the Author:

Steve Yurjevich, vice president and general manager, has been with Optum for seven years. He joined Optum through the acquisition of Aim Healthcare, a nationwide payment integrity player, where he held several roles as vice president of operations for more than eight years. Prior to that, Steve worked in CSC Healthcare’s consulting division working with payers on claims payment system modernization and management consulting.

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