Each year, the healthcare industry is estimated to lose tens of billions of dollars due to fraud. While conservative estimates put that at 3% of total healthcare costs, other reports place that loss as high as 10% — representing a huge, often preventable, expense for organizations.
Fraud, waste, and abuse (FWA) stemming from over-billing, errors in claims, and unnecessary healthcare services remain a persistent and expensive challenge for industry leaders, especially as overall healthcare costs continue to rise year after year.
Minimizing these unnecessary costs, therefore, is a critical priority for Vālenz Health® and our dedicated iThrive Customer Council in 2025 — and the reason why integrating advanced, data-driven payment integrity solutions is high on our list of recommended plan optimizations for healthcare leaders.
Editor’s note: This blog is part of a three-part series addressing the iThrive Customer Council’s top priorities for 2025. Read the annual report in full here.
In a nutshell, payment integrity solutions are part of a comprehensive approach that analyzes insurance claims and bills before, during, and after the payment process to identify errors and verify costs. These strategies help ensure the correct people are billed for the correct amount, preventing overcharges, protecting patients, medical practices, and everyone involved in claims processing.
We’ve discussed at length the features to look for choosing the right payment integrity solution for your organization. But, as certain trends dominate the headlines in 2025, there are a few additional considerations to make when optimizing your payment integrity solution suite for maximum savings and minimum risk.
As today's Americans report higher financial pressure than ever from their healthcare-related expenses, payment integrity solutions can play a key role in shielding members and plan payers from unnecessary, unsustainable costs.
But, in focusing on post-payment recovery, many payment integrity strategies overlook the importance of proactive claims review — a strategy that prevents stakeholders from having to pay those unnecessary expenses in the first place.
In 2025, the best payment integrity solutions should offer multiple layers of validation and protection for both employers and employees throughout the healthcare journey.
By engaging in all three phases of what we call the Claim Cost ArcSM (proactively, concurrently, and retrospectively), highly optimized payment integrity strategies can make an even bigger impact in preventing FWA for self-insured employers, their employees, and other plan payers.
In short, to perform at their highest level and maximize savings for stakeholders, payment integrity solutions in 2025 must prioritize ongoing, proactive fraud detection and prevention, aided by continuous monitoring by certified experts, like those that Valenz employs for our industry-leading Payment Integrity solutions.
In the face of renewed federal focus on healthcare pricing transparency, proper fiduciary responsibility over plan assets must remain a high priority for plan providers. Payment integrity initiatives can help support this responsibility — ensuring that only reasonable and necessary costs are borne by the plan.
Healthcare pricing has long been a topic of discussion in federal and state legislatures. Earlier this year, the Trump administration released the first in a series of executive orders re-emphasizing the demands set by the first administration in 2019. These original demands eventually became the Transparency in Coverage (TiC) rules and the No Surprises Act (NSA), both of which emphasized pricing transparency to protect consumers from unexpected expenses and inconsistent billing practices.
The 2025 executive orders follow the same pattern, requiring stricter enforcement of those laws, as well as new regulations around prescription drug cost-containment and PBM compensation transparency.
While the specific effects and requirements of these executive orders remain to be seen, healthcare leaders can get ahead of new compliance demands (and meet those set by the TiC and NSA) by integrating strategic, comprehensive payment integrity solutions this year.
(If you need help making it happen, contact our team members today.)
Artificial intelligence (AI) is drastically transforming the healthcare industry, requiring plan designers to thoughtfully, strategically consider how to best implement these programs without harming existing systems — including payment integrity processes.
We expect AI to play an increased role in streamlining payment integrity efficiency and effectiveness in 2025 and beyond. In our ongoing pursuit toward smarter, better, faster healthcare, AI brings a speed of data-driven review that cannot be matched by a single human auditor.
However, when implementing AI into payment integrity services, healthcare leaders cannot overlook the importance of those human experts. We predict industry-leading organizations will take a balanced, measured approach.
For example, by deploying AI tools for high-volume data analysis, human auditors can significantly reduce their administrative burden — reserving manual, expert review for those complex, high-dollar claims cases identified and prioritized by automation.
The result: Improved efficiency and accuracy of the entire review process, without the risks introduced by relying solely on AI systems.
Together, AI review and expert human intelligence should form a complementary partnership in 2025, one that supports more precise, efficient outcomes across the entire healthcare continuum, but especially when it comes to payment integrity initiatives.
As we look to a future where healthcare costs continue to rise, we expect payment integrity solutions to play an increasingly important role for plan administrators, payers, providers, and patients alike. When implemented properly, these initiatives hold great promise for simplifying existing complexities and facilitating smarter, better, faster healthcare for all — which is why it rounds out our list of top priorities for the year to come.
To review our other iThrive Council priorities for 2025, read the previous blogs in this series below:
In the meantime, if you wish to explore how payment integrity solutions or any of our other iThrive priorities can help you optimize your healthcare benefits packages, connect with our team members now.