In the complex ecosystem of American healthcare, a quiet but high-stakes battle is unfolding. On one side stands the Revenue Cycle Management (RCM) industry, a $140 billion behemoth that is currently larger than the U.S. auto industry and growing five times faster. Armed with sophisticated AI and programmatic tools, RCM vendors are dedicated to a single goal: maximizing every cent of revenue squeezed from a medical claim. On the other side sits the self-insured employer, often relying on legacy processes and conflicted vendors who may be, as Stacey Richter puts it, "effectively phoning it in."

In a recent episode of the Relentless Health Value podcast, Mark Noel, SVP and GM of ClaimInsight at AMPS, joined host Stacey Richter to discuss the urgent need for a "prepayment integrity" revolution. The conversation, part of the show's "Inches Are All Around Us" series, explores how the lack of integrated, unconflicted payment oversight has left plan sponsors bringing a knife to a gunfight.

The Small Claim Gold Mine

One of the most significant revelations from the discussion is the industry's obsession with "million-dollar babies," the rare, high-cost catastrophic cases. While these claims are eye-catching, they represent only a fraction of the total opportunity for savings. Noel points out that 80% of claim volume resides in professional, small-dollar claims such as routine doctor visits and lab work.

Because these claims often fall under a certain dollar threshold, many Third-Party Administrators (TPAs) and carriers simply let them fly through without scrutiny. However, overpaying or double-billing by just $5 or $10 on thousands of claims quickly scales into millions of dollars in waste. As Noel explains, finding these "inches" requires a shift to programmatic prepayment review, since the administrative cost of paying and chasing a $10 error after the fact is rarely worth the effort.

The Conflict of Interest Trap

The podcast pulls no punches regarding the structural flaws in the current TPA and ASO model. Noel argues that it is a fundamental business mistake to hire the same entity to both process claims and audit their own accuracy. Asking a TPA to report on its own adjudication errors is an inherent conflict of interest that rarely benefits the plan sponsor.

Furthermore, many carrier contracts include shared savings provisions. This creates a perverse financial incentive. A carrier may profit more by letting an error slip through the front end, then charging a 30% contingency fee to recover that same money on the back end. This pay-and-chase loop turns administrative failure into a profit center, leaving the employer to cover both the initial overpayment and the recovery fee.

Bridging the Payer Paradox

The solution lies in demanding unconflicted, real-time expertise. Noel emphasizes that payment integrity should not be a black box of denials that creates provider abrasion. Instead, it should be a transparent, physician-led process that ensures claims are accurate before the check is cut. This proactive approach protects the plan's bottom line and supports members directly. With 41% of Americans struggling with medical debt, ensuring claims are not wrongly inflated is both a fiduciary and moral imperative for plan sponsors.

To stay competitive in the RCM arms race, employers must move beyond "good enough" oversight and embrace a strategy built on transparency, clinical depth, and immediate accuracy.

Listen to the Full Episode

To hear the full discussion on how to reclaim these inches of waste and protect plan assets, listen to the full podcast episode here:
https://relentlesshealthvalue.com/episode/ep498-the-payment-integrity-arms-race-rcm-revenue-cycle-management-and-plan-sponsors-with-mark-noel

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