With rising costs and increasing complexities in healthcare and claims processing, payers must adopt proactive solutions to ensure payment accuracy, minimize financial waste, and uphold compliance.
Strong payment integrity services do more than catch errors; they also prevent them. By leveraging advanced analytics, expert oversight, and seamless integration, organizations can reduce fraud, waste, and abuse (FWA) while enhancing operational efficiency.
In this guide, learn more about what payment integrity services are, how they work, and the characteristics to look for when finding the right solutions provider for your needs.
Payment integrity is a comprehensive approach that analyzes bills during the payment process to identify errors and verify costs. Ensuring the correct people are billed for the correct amount helps prevent overcharges, protecting patients, medical practices, and everyone involved in processing and supporting the claims process.
A payment integrity program is essential to reducing costs, boosting efficiency, and improving patient outcomes. With a well-designed program, organizations can experience significant cost savings and minimize financial inefficiencies. It can also lead to better relationships with providers and members.
Here at Vālenz Health®, payment integrity solutions have helped our clients save millions of dollars, with one health plan provider saving an average of $40,000 per claim.
A well-designed payment integrity program is key to maximizing savings on member claims. The most effective programs typically include the following features:
Data analytics plays a vital role in ensuring payment accuracy and reducing waste by uncovering patterns, anomalies, and potential fraud within vast datasets. By leveraging AI-driven insights, organizations can detect billing irregularities and prevent costly overpayments, ultimately strengthening financial and operational efficiency.
Integrating AI throughout the claims life cycle — from pre-authorization and care delivery to claims processing and reimbursement — creates a smarter, more proactive approach to payment accuracy.
With solutions such as Full Claim Review by Valenz, AI-powered insights are combined with expert coding and clinical review teams to validate both in-network and out-of-network claims, ensuring care is medically necessary and provided by licensed providers.
Additionally, VMS® Market-Sensitive Repricing combines advanced analytics, expertly curated data, and cost intelligence to help Valenz uncover added savings on high-cost, low-utilization claims. This seamless approach enhances healthcare payment integrity, driving significant savings while improving the overall claims experience.
The National Health Care Anti-Fraud Association estimates as much as $300 billion of healthcare spending is lost to fraud each year. AI tools and machine learning algorithms can help prevent these costly errors, financial losses, and billing inefficiencies. By proactively identifying irregular billing patterns, duplicate claims, and unnecessary procedures, these technologies can help address issues before they escalate, saving time and money.
Proactive AI usage enhances payment accuracy, improves trust in the system, and reduces overall healthcare costs. It can also help prevent claims denials, ensure compliance, and mitigate legal risks, creating a smarter, more efficient approach to healthcare payments.
Ensuring payment accuracy requires a strategic balance between AI-powered analytics and expert human oversight. A comprehensive claims review process can help prevent errors, ensure compliance, and safeguard against fraudulent or unnecessary claims.
With Full Claim Review from Valenz, nurses perform claim reviews, including complex claims and physician or expert peer reviews. Claims are also evaluated for improper, unbundling, and upcoding of medical services, equipment, and supplies, and a line-item bill review is performed to verify that the services were medically necessary.
By leveraging advanced AI, discrepancies in billing patterns can be detected quickly. At the same time, expert coding and clinical review teams strengthen the review process by applying critical judgment and regulatory expertise. This powerful combination verifies that services were medically necessary, provided by credentialed providers, and aligned with contractual requirements, reducing the risk of overpayment and fraudulent claims.
The results? Fewer claims denials, fair reimbursements, a more efficient and accurate review process, and the removal of tedious and manual efforts from an organization’s administrative offices.
A strong payment integrity service catches and prevents errors at the moment they occur. Thus, continuous monitoring is critical to maintaining integrity, ensuring compliance, and identifying areas for improvement.
Identifying and correcting any errors related to documentation and billing for patient care as they occur can:
Payment integrity services should integrate smoothly with existing healthcare IT infrastructure. This ensures health plans, providers, and payers can access real-time data without disrupting workflow or requiring extensive system overhauls.
By embedding directly into existing infrastructures, payment integrity services can automate processes, reduce manual errors, and improve operational efficiency. This allows organizations to focus on delivering cost-effective, high-quality care while maintaining financial and compliance integrity.
The payment integrity tools that Valenz offers are designed to integrate effortlessly with health plans’ existing systems. By improving workflow and data accuracy, these tools optimize claims management and empower organizations to proactively manage healthcare costs.
Collaboration between payers and providers is essential to resolving payment issues efficiently and transparently. When working together, discrepancies can be identified quickly while reducing disputes and streamlining the payment process, leading to financial and operational outcomes that strengthen trust, efficiency, and compliance.
Ensuring payment integrity in healthcare requires a proactive, data-driven approach that balances technology, human expertise, and seamless collaboration. By prioritizing accuracy, efficiency, and compliance, organizations can create a better payment system that benefits payers, providers, and patients alike.
Connect with Valenz today to learn more about our payment integrity solutions.