As medical spending continues to rise, payment integrity is becoming a more strategic lever for health plan performance. In this interview, Mark Noel, General Manager and Senior Vice President of ClaimInsight at AMPS, explores how the market is shifting and why health plans are demanding a more transparent, accountable approach to claims accuracy and vendor partnerships.

Noel explains how the conversation has moved beyond identifying overpayments to building systems that deliver continuous visibility, stronger financial accountability and greater control over policy logic. As health plans become more sophisticated buyers, they are looking for payment integrity models that evolve in real time and align more closely with long-term enterprise goals.

The discussion also examines why high-dollar inpatient claims remain a critical pressure point and how physician-led reviews, paired with detailed bill analysis, can help plans act earlier in the payment lifecycle. The result is not only stronger savings retention, but a more durable strategy for reducing appeal risk and improving confidence in payment decisions.

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Full Interview Transcript

Fierce Healthcare: We are seeing medical spending at a high. The US is projected to hit $6 trillion in expenditure, and one of the challenges we're seeing is ensuring accurate and efficient claims payment. Payment integrity has been part of health payment operations for decades. What's different about the environment health plans are navigating right now?

Mark Noel: There's a couple things I'd point out. Number one, plans are just more educated now—both on the financial side and the operational side. Historically, it's been about finding savings, reporting those savings, collecting fees, and moving on. Financially, these folks are getting way more educated: they don't want to just pay you for what you found. What if something happens down the road and that claim gets adjusted or repriced?

That's why we incorporate a whole history process. Once we receive a claim, anytime that claim changes in the client's system in the future, we continue to receive it and learn what's updated. If they completely back out and deny the edit we made, we don't get paid for that—or if we had been paid in the past, we actually give that back. That's an important thing we talk about a lot with prospects and clients.

Operationally, there's also a big shift around transparency. There's been this notion of a black box in payment integrity for many years. We want to make sure it's their policy, not ours. We're just helping them administer it. We happen to have the means and mechanism to get all the content, but it's really theirs. We keep them along for the ride every step of the way, and at any time they have access to all of the content. That's how we become a win-win partnership.

FH: So it sounds like you're trying to be more proactive instead of reactive.

MN: Yeah, way more proactive. We talk about it upfront. They make decisions—it's not our decision. And that theme carries through in everything we do.

FH: Where does the financial exposure actually land for health plans when a payment integrity program underperforms?

MN: There are several areas. I'll start with high-dollar claims. The volume of high-dollar claims is lower than small professional claims, but they make up the vast majority of claims spend. The more attention you can put on high-dollar claims, the better.

Our high-dollar review program takes those claims line-by-line and looks at every single line from the itemized bill. We're not just looking at medical records—we're actually looking at the itemized bill and saying, "You've already paid for a bundled charge for this day for the ICU. Why should you also pay for pillows, blankets, and aspirin?" Taking those things into account is a major differentiator.

Another area is appeal erosion. As things get appealed and disputed after payment, managing those is another big piece. When we do those high-dollar reviews, we actually manage and own those appeals all the way through. It takes the burden off the client and ensures the financials stay intact. Since we have physicians doing our reviews, the vast majority do not get overturned. We're able to say, "No, this is what we found and this is why." Because it was done by a physician, it brings that backing with it.

FH: Having a physician provide that insight can avoid additional friction in those appeals.

MN: Exactly right. Another area of exposure is moving things from post-pay to prepay. You'll see groups doing a lot of post-pay reviews now, but moving those up into prepay is huge. One thing that's really important in doing prepaid is making sure all the policies and edits are up to date as of the effective date. That's a huge differentiator. There's still so much leakage that gets through. Being a managed service, we're able to keep those up to date. When you're working with some vendors on a subscription basis, they send a disc every quarter—you're already three months behind. Capturing those savings within that three months is huge.

FH: Real-time helps save money at the end of the day.

MN: Exactly.

FH: There's a lot of conversation about transparency and payment integrity. What does that actually look like at the operational level for a health plan?

MN: Along with health plans being more educated, I'd say they're also staffing up more—bringing as much payment integrity in-house as possible. What that means from a transparency perspective is: if they're working with a vendor like us, they want to have the ability to learn from us and bring as much of that in-house as they can. We've taken a different approach in the market—we're open to doing that. We have some clients where we're actually helping their payment integrity staff do better at what they do. We realize that takes away from our future savings, but that's okay. If it's a win-win partnership, we're all open to it. Not a lot of other folks are taking that method, but it's been very successful for us.

FH: High-dollar inpatient claims come up frequently in payment integrity conversations. Why do you think those cases represent such a distinct challenge today?

MN: One reason is those claims can be billed in many different ways—DRGs, percent of bill, percent of charges. Simply having all these different ways means pricing can go ary in many ways. With our methodology of actually grabbing the itemized bill, there's no better way to see what was actually performed. That itemized bill shows every single thing—pillows, blankets, toothbrush—everything. If you think about building a house, it talks about every nail, every hammer, every piece of wood.

The other big differentiator is because we use physicians in those reviews, we're able to not only take out things that should be bundled, but add a layer of judgment. We'll see a claim for a NICU claim billed at level five, yet that patient went home two hours later. The MD is able to add their judgment and say, "Based on everything I see, this is not a level five—this is actually a level three." Being able to add that down-coding component based on a physician is really important and adds a ton of savings.

FH: And for both the patient and the provider side as well.

MN: Exactly right. Again, when we have physicians do those high-dollar reviews and we own the appeals and disputes, the moment anything comes back and the provider says, "I don't really agree with this," it comes right back to us. In many cases, we have physician-to-physician talking about why the service was done and why it was billed that way. We're saying, "Based on national coding guidelines, here's why we shouldn't be paying for this." Getting them to talk has been really good.

FH: That's critical, especially when a payer and provider might have gaps in knowledge—provider-to-provider helps expedite the process.

MN: That's right.

FH: Can you share how ClaimInsight is approached or structured differently from what health plans typically encounter in the market?

MN: First and foremost, our whole premise is based on wanting a win-win partnership with our clients. I don't ever want a case where I'm making a bunch of money off them but not really meeting their objectives. Therefore, one differentiator is I'm not trying to just solve one problem—editing claims to create savings and making money off that savings. I take the opportunity to say, "Let's understand what your problems are, what objectives you're trying to meet, and tailor our program to that."

Specifically, if you want to make your internal payment integrity program stronger, let's talk about how we can do that. I have all the resources. We've proven we're good at researching content, building content, and maintaining it. If that's where I can help you, happy to help you there.

I have an example where a new Medicaid plan came to us—they had no payment integrity at all, in two states we had never worked with before. We researched, built, and maintained all that content in about 45 days, start to finish. That speaks to our ability to quickly and efficiently—with high accuracy—build brand-new content. We're happy to share that with folks to remove the transparency barrier and help them build what makes the most sense for them.

FH: For a health plan leader who wants to get a clear picture of where their program actually stands, what would that process look like?

MN: We do it in a couple of ways, and both result in actual results based on their actual data. We don't guess. We don't come up with fictitious numbers. Our goal is always to underpromise and overdeliver.

First, give us your claims data—the last six months—and we'll run it through our automated editing program and show you exactly what was missed. Again, it's not about trying to say where another vendor isn't as good. We just speak with the facts. We can tell you based on that data there are several million dollars in overpayments that aren't being covered today.

Specifically for high-dollar claims, we literally say, "You must have a couple of high-dollar claims you've been trying to manage. Send us one or two. Give us the itemized bill and we'll go through it at no cost." We'll show you the real savings, what you missed, and where you're overpaying. Honestly, that's the biggest selling point for us—no cost, send us your data, and we'll walk through line by line.

FH: To wrap up, it sounds like you're really helping health plans build a framework that is accurate, transparent, resilient, and not just helping with claims but alleviating administrative burden.

MN: That's right. We're not in the business of just creating edits to create savings and fees. If those edits are going to create noise down the road, that's not helpful to anybody. We have constant feedback loops of understanding and learning from any appeals and disputes. We go back to the beginning and say, "Is this a problem with the edit? Is this just a problem in this area? Or maybe you're okay with this provider billing like this for this scenario." We're constantly using that feedback loop to update the front of the process. The more automation, the better.

About Advanced Medical Pricing Solutions

AMPS is a healthcare cost savings technology company helping organizations take control of rising healthcare costs while delivering a better, more supported member experience. With over two decades of experience, we bring together medical claims strategy, 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 Healthcare Cost Savings, AMPLIFIED. For more information visit www.AMPS.com.

AMPS is a proud sponsor of Fierce Healthcare.‍