Process ingenuity
Increasingly, payers are shifting from the traditional pay-and-chase or post-pay model to a more preventive focus—for accurate, pay-right-the-first-time model. A proactive and preventative post- to pre-pay approach exponentially drives down inaccuracies and overpayments, with identification and recoupment for payers’ overtime.

The right partner to assist with this model has legacy healthcare services/PI expertise, supported by proven process excellence in claims selection, claims audit, overpayment validation, recovery operations performing end-to-end audit programs or enabling payer’s PI teams with business process augmentation. In this new era, payers are equipped with technology and tools but lack PI experienced resources to perform audits and set up processes. Healthcare services partners in this space can address this need for payers.
The value of a shift from post- to pre-pay audit is to:

• Increase provider-payer collaboration
• Reduce provider abrasion
• Reduce administrative cost

Accurate payment requires accurate billing—if both of these outcomes are not occurring, overpayment is the result. With PI audits in post-pay, administrative costs increase for the payer and provider abrasion is increased. The optimal focus is pre-pay in order to pay right the first time. This allows timely submission of accurate documentation, for example. Provider response is not optimized in post-pay audits.

All accelerated by tech enablement
How is today’s tech enablement finally solving for PI challenges of yesterday? The answer lies in a triangulated approach of rules/concepts, and claims repricing and validation, with AI/machine learning models driving quantified outcomes with intelligent automation driving more accurate findings and reducing false positives.

Today’s payment integrity is perhaps one of the best use cases for both the myth and reality of AI promise. Payers are using AI to determine how claims will be paid and making the critical decisions. Providers are using AI to appeal all denied claims. AI—when bolstered by robotic process automation (RPA) and intelligent automation—is at its best in areas of payment integrity.

The promise of AI and accompanying tech enablement is particularly appealing for payment integrity, due to the complexity of healthcare data and various forms of data—claims, contracts, medical records and policies—along with changing guidelines. The traditional querying of data through defined and domain-led and human-created business rules has been well tested in payment integrity. We are in early stages of how artificial intelligence will come into play. The right healthcare services expert can lead on what tech enablement to leverage to optimize the resources, domain knowledge, and process ingenuity that drives real and measurable outcomes in the payment integrity space.

About the author: Subrahmanyam Mantha is vice president, Payment Integrity Practice at Sagility. He is an accomplished senior management executive with strong operations and leadership skills to build business verticals and organizations in the BPO/KPO/Analytics space in insurance, healthcare, and financial services.

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