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 1. Home
 2. HealthEdge Blog
 3. New Research Results: Top 5 Trends in Payment Integrity for Health Plans


NEW RESEARCH RESULTS: TOP 5 TRENDS IN PAYMENT INTEGRITY FOR HEALTH PLANS

Published Date June 23, 2023 Author HealthEdge


 * 
 * 
 * 
 * 

In90group Research recently hosted a webinar with AHIP and HealthEdge to release
findings from a new study of more than 100 health plan leaders regarding the
current state of payment integrity and how health plans are approaching their
payment integrity strategies for 2025.

Based on the data, it appears that health plans should consider a fresh approach
to payment integrity across their enterprise to help tackle some of their
long-standing and most frustrating challenges. The highly interactive webinar
featured Ryan Mooney, EVP and GM, HealthEdge Source and Carl Anderson, Carl
Anderson, Senior Product Manager HealthEdge Source sharing their perspectives on
the data.

To watch the full webinar, click here: New Research In Payment Integrity Reveals
a Paradigm Shift is Underway.

We’ve summarized the five key findings in this post.

5 Take-Aways From the New Research

 1. Workforce Shortages and Limited Resources: A significant challenge faced by
    payer organizations is the limited availability of qualified resources to
    ensure accurate claims payment. The webinar revealed that 64% of respondents
    ranked limited resources as one of their top issues, preventing them from
    keeping up with changing fee schedules and policy updates. Additionally, 58%
    expressed difficulty in hiring and retaining qualified professionals for
    this complex work. These challenges may arise due to the manual labor
    involved in ensuring accurate claim payments.
 2. Limited Visibility and Root Cause Issues: Another prominent challenge
    identified by payers is the limited visibility into third-party vendors and
    root cause issues. Without comprehensive visibility, payers struggle to
    identify the underlying causes of payment errors and address them
    effectively. This lack of insight leads to a cascade of problems, such as
    increasing workload and growing financial losses. Achieving transparency and
    identifying root causes are crucial for building effective payment integrity
    programs.
 3. Manual Rework and Costly Errors: More than half of the respondents revealed
    that over 20% of their claims required rework, which incurs significant
    costs ranging from $25 to $181 per claim. The financial burden resulting
    from these errors extends beyond rework expenses and includes factors like
    provider dissatisfaction and member dissatisfaction. To address this issue,
    payers need to focus on getting claims right on the first attempt.
 4. Misaligned Initiatives: While payment integrity initiatives involve multiple
    departments within an organization, misalignment often hinders their
    effectiveness. The webinar findings indicated that over half of the
    respondents felt that their organization’s payment integrity initiatives
    were at odds with other initiatives. This misalignment can be attributed to
    a lack of a common goal across departments, competing priorities, and
    stretched resources. Achieving a more holistic enterprise approach is vital
    for overcoming these challenges and ensuring a unified payment integrity
    program.
 5. Misaligned Vendor Incentives: Many payers struggle with the burden of
    multiple third-party vendors, resulting in increased costs and complexities.
    In the webinar, the speakers highlighted the challenges faced by payers when
    using several editing tools stacked on top of each other. These challenges
    include maintaining multiple IT systems, managing conflicting content, and
    navigating fragmented workflows. Consolidating vendor relationships and
    adopting a single, unified platform can help reduce costs, streamline
    operations, and enhance efficiency.

The Path Forward: Technology as a Solution

Historically, technology has taken a backseat to content when it comes to
selecting payment integrity vendors. However, the webinar highlighted a shift in
focus, with technology emerging as a critical component in overcoming payment
integrity challenges. Payers are realizing that technology can provide solutions
and streamline processes that manual labor alone cannot achieve. By leveraging
modern and flexible technology, payers can effectively tackle rising
complexities and improve their payment integrity initiatives.

To address the challenges identified in the webinar, HealthEdge Source delivers
a modern technology platform that gives payers the ability to access pricing and
policy changes from a single place, thereby improving transparency and
streamlining operations. By leveraging technology, payers can achieve greater
control, visibility, and interoperability within their payment integrity
initiatives. Additionally, technology empowers payers to reduce dependency on
contingency vendors and address root cause issues, resulting in improved
accuracy and savings.

To learn more about how Source can help your organization achieve its payment
integrity goals, visit Prospective Payment Integrity – HealthEdge.

 


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