Medicine is complex. Fragmentation, rising costs, and constantly evolving regulations are challenges across health plans, patients, partners, and providers. With this complexity and increasing volume of medical insurance claims, improper insurance payments show no signs of slowing down. In fact, the 2025 Comprehensive Error Rate Testing (CERT) program showed an improper payment rate of 6.55%.
Payment alignment may be one of the biggest cost control levers for health plans, but some organizations continue to struggle to bring their programs to a point where they can scale and grow toward year-over-year value gains.
Prepaid and postpaid connections
Achieving future-proof payments integrity requires a fully connected ecosystem with the right technology and logic to enable organizations to intelligently leverage automation and prevention, integrate prepaid and postpaid for comprehensive monitoring, and participate in payment continuity as early as possible.
However, there are many potential problems that hinder this ecosystem. for example:
- fragmented data
- Imperfect analysis and technology
- Lack of resources to maintain policies
- There is a shortage of human experts
- Prepaid and postpaid connections have been disconnected
To enable this ecosystem, technology and data gaps must be addressed to ensure meaningful analysis and interventions are based on complete and accurate information. for example:
- Critical data elements in file formats that provide upfront payment integrity solutions, such as outpatient, inpatient, pharmaceutical, or other claim types, are often missing and must be addressed. Member matching data. or exact membership status.
- If applicable, invoice hold functionality must be added to the prepayment workflow to effectively hold and retrieve documents, but this does not exceed the immediate payment guidelines.
- The concept of postpaid intervention must be comprehensive and closely synchronized with the various prepaid intervention systems. Because without both, we either lack ideas for expert intervention to shift to the left, or our ability to shift is limited.
Strongly connected prepaid and postpaid systems also incorporate the effective and responsible use of AI. AI should enhance capabilities by better identifying patterns, summarizing complex medical documentation, and supporting billing and policy decision-making. That said, AI is a tool, not a solution. AI should not replace human expertise, especially in the medical field. Plans should strategically limit AI automation to allow human experts to improve performance and outcomes. This means it is not intended to replace human clinical decision-making or judgment. Organizations can use AI to help prepare clinical content, but not to make decisions based on that content.
Cotiviti believes that if connected prepaid and postpaid systems are applied with the right technology, data orchestration, mix of interventions, and responsible use of AI, organizations can expect approximately 70% or more of their payment integrity programs to be run in prepaid mode, with the remaining 30% postpaid to tackle the most challenging scenarios, such as retroactive data changes, ordering and re-pricing, exclusion of certain providers, and pre-authorization restrictions.
The path forward to achieving payment integrity
What happens next for payment integrity once a truly connected prepaid and postpaid system is in place? Early intervention in the claims payment process is key to future payment integrity. These advance rulings or preemptive actions complete the picture and ultimately produce cleaner claims, significantly reducing administrative costs for both payers and providers.
Payers need to consider moving from purely vertical, isolated touchpoints to a continuum. For example, an intervention point that attempts to do the following:
- Intervene at the earliest point for maximum effectiveness
- Accelerate value realization through multiple interventions delivered through a common platform
- Integrates into existing workflows and complements existing solutions
- Incorporate AI into interventions to create self-correcting and learning processes
Combining advanced analytics such as machine learning and AI with robust data orchestration creates the potential for scalable payment integrity and MLR and ALR reduction. Combining this innovation with expertise and experience is critical to closing the gap, strengthening provider relationships, and maintaining high levels of confidence in the accuracy and preventability of early intervention.
Ultimately, future-proofing payment integrity means creating a cleaner, more connected, and more transparent claims payment continuum. Plans that take this end-to-end approach will be better equipped to adapt, evolve, and lead as the healthcare landscape continues to change.
To learn more about expanding our payment integrity efforts, read the full eBook Future-proofing Payment Integrity.
