Improper spending is an enormous problem in healthcare. According to the Centers for Medicare and Medicaid (CMS), Americans spent $4.1 trillion on healthcare in 2020, of which an estimated $1.2 trillion can be attributed to some form of waste or abuse that leads to overcharges.  One tool healthcare payors can use to reduce the overpayments that occur as a result of incorrect, wasteful or abusive billing practices is a payment integrity solution. 

What do payment integrity solutions do?

There are several types of payment integrity solutions.  Overall, they ensure a claim is paid correctly by verifying:

  • The responsible party pays the claim.
  • The claim is properly coded.
  • The claim is coded in a way that is applicable to the diagnosis.
  • The claim is paid in accordance with health plan policies.

A comprehensive payment integrity solution typically consists of several different services that together accomplish all of the above.

When are payment integrity solutions used?

Payment integrity solutions can be used before or after a claim is paid.  An advantage of using a prepayment solution whenever possible is that not only does the solution generate savings by correcting the issue before a claim is paid, it also eliminates the need to allocate resources to re-process claims and/or recover overpayments if an error is found after the claim is paid.

An important consideration for a post-payment integrity solution is whether the solution helps the payor to avoid the same issue from occurring in the future. That is, once an issue is identified post-payment, the root cause should be corrected and then, ideally, also captured in a prepayment solution so that the issue doesn’t lead to future overpayments.

Payment integrity solutions work together

 If you’re already using a payment integrity solution, it’s important to know that adding a new one to your claim processing doesn’t necessarily mean eliminating the one you’re already using. Payment integrity solutions from different vendors can work together. Many healthcare payors use a stacked approach, putting one solution behind the next to catch more errors.

Learn about ĤƵ’s Payment and Revenue Integrity services here.