Payment Integrity partners should not be an issue
Spring is the season for audits, updates, and difficult conversations. And for a growing number of health plans, one of those difficult conversations is around payment integrity vendors.
I often hear people say, “Even though we’ve been together for years, nothing has changed.”
The medical billing environment has completely changed. If your payment integrity program isn’t keeping up, the gap between what you’re paying and what you should be paying is widening every day.
The scale of the problem is not small.
Let’s start with the numbers, because they’re hard to ignore.
In 2025, the U.S. Department of Health and Human Services reported $16.6 billion in health care fraud, improper payments, and overpayments, but this number represents only what was identified and reported. Some estimates suggest that more than 20% of improper payments are missed by traditional payment integrity solutions, costing health care payers more than $500 billion in hidden losses each year.
Please read it again. 5 trillion dollars. Every year.
These are not abstract industry numbers. These directly translate into drains from plans, higher premiums for members, and relationships with vendors who may be providing a fraction of their potential.
Meanwhile, the forces driving spending are growing stronger. From 2021 to 2023, healthcare spending by employers on pharmacies will increase from 21% to 27%, and healthcare spending as a share of GDP continues to increase as healthcare inflation outpaces overall inflation. Older and sicker populations have access to more expensive treatments, and the associated billing complexities dramatically increase the opportunities for errors, upcoding, and overpayments.
The market is evolving. Your vendor may not.
The global payments integrity market is expected to reach $8.26 billion in 2025 and grow to $34.82 billion by 2035 at a compound annual growth rate of 15.5%. This growth is a clear sign that the demand for better solutions is real and accelerating.
However, market growth does not mean that current vendors will grow with it.
For too long, payment integrity has been primarily reactive, catching errors after a claim has been paid. That model is no longer sufficient. Most payers are now shifting their strategies to pre-payment reviews to identify mistakes before a claim is finalized and protect medical loss rates before money leaves the plan. Investments in prepaid solutions are growing twice as fast as traditional models, with a CAGR of 26% compared to 13% for postpaid.
The industry recognizes what the best health plans already know: it is pre-adjudication interventions that have real impact. If the market is moving toward proactive, integrated payment monitoring, but your vendor is still leading with a pay-first approach, your program is already behind the curve.
Many health plans manage relationships with three to seven vendors for the sole purpose of payment alignment, creating unnecessary complexity, siled insights, and accountability gaps that are nearly impossible to close. Sound familiar?
cost of staying
We understand the hesitation. Evaluating a new vendor means determining the very real significance of contracts, existing relationships, and organizational changes. That’s not a small question. But it’s worth weighing that against something that’s often overlooked. It’s the steadily compounding cost of a program that can’t stop errors before they occur.
Fraudulent payment claims not only create financial risks but also set new standards. Members bear the downstream consequences of billing errors that should have been discovered before award, and fee structures that initially seemed reasonable can quietly erode the value of every dollar the vendor was supposed to protect in the first place.
If “good enough” has become an expectation, it may be time to recalibrate what a truly proactive program can actually deliver.
What does a clean slate look like?
AMPS’ payment integrity solution, ClaimInsight, is built on a simple premise. Payments integrity means you need to stop errors before they occur, rather than cleaning them up after the fact.
it starts with Intelligent Policy Update (IPU)layers accuracy across the entire claim stream, across all claims, regardless of size or type, reducing leakage without adding friction. Built on that foundation, High priced reviews (HDR)applies clinical and billing expertise before high-value claims are adjudicated and detects errors at the point where intervention has the most impact. Together, they form a unified upfront defense across the business, rather than a patchwork of disconnected point vendors.
It means a transparent methodology — Understand exactly how savings are determined, what the results mean, and how they are calculated. There are no black boxes. No surprises.
That means aligning incentives — A model built to maximize planning outcomes, not to optimize margins.
it means true partnership — Clear reporting, consistent communication, and defensible results so you never have to wonder what you’re getting.
We are not asking you to take our word for it. Ask your current vendor some tougher questions and see what you get back.
May is a good time to see
The contract will be renewed. Shifts in the planning year. The budget cycle has been reset. As your current payment integrity program approaches or requires review, there is no better time to consider what a more proactive, integrated approach can achieve.
Healthcare industry leaders are under increasing pressure to demonstrate tangible returns on their payments integrity investments. The question is whether your current partner has what it takes to help you meet that criteria, or whether it’s time to find one.
Let’s talk about things going through that shouldn’t go through.
About Advanced Medical Pricing Solutions
AMPS is a healthcare cost reduction technology company that helps organizations manage rising healthcare costs while delivering a better, more supported member experience. With over 20 years of experience, we integrate medical billing strategies, payment integrity and pharmacy benefits into a connected ecosystem designed to reduce costs, improve accuracy and support the people behind every claim. Through our three solutions (ClaimInsight, PriceDynamix, and Drexi), we deliver significant healthcare cost savings. Learn more here www.AMPS.com or www.ClaimInsight.com
