Spring is the season of audits, renewals, and hard conversations. And for a growing number of health plans, one of those hard conversations is about their payment integrity vendor.

We hear it regularly: “We’ve been with them for years and nothing’s really changed.”

The healthcare billing environment has absolutely changed. If your payment integrity program hasn’t kept pace, the gap between what you’re paying and what you should be paying is growing by the 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 healthcare fraud, improper payments, and overpayments and that figure represents only what was identified and reported. Some estimates suggest that 20% or more of improper payments are missed by traditional payment integrity solutions, leading to over $500 billion in unidentified losses for healthcare payers each year.

Read that again. Half a trillion dollars. Annually.

These aren’t abstract industry figures. They translate directly into dollars leaving your plan, inflated premiums for your members, and a vendor relationship that may be delivering a fraction of its potential.

Meanwhile, the forces driving spend are intensifying. From 2021 to 2023, employer healthcare dollars spent on pharmacy increased from 21% to 27%, and healthcare’s share of GDP continues to grow as medical inflation outpaces overall inflation. An older, sicker population is using more expensive treatments, and the billing complexity that follows creates exponentially more opportunity for errors, upcoding, and overpayment.

The Market Is Evolving. Your Vendor May Not Be.

The global payment integrity market reached $8.26 billion in 2025 and is projected to grow to $34.82 billion by 2035, at a compound annual growth rate of 15.5%. That kind of growth signals one thing clearly: the demand for better solutions is real, and it’s accelerating.

But market growth doesn’t mean your current vendor is growing with it.

For too long, payment integrity has been primarily reactive, catching the error after the claim pays. That model is no longer sufficient. Most payers are now shifting their strategies toward pre-payment review: identifying errors before claims finalize, protecting medical loss ratio before money ever leaves the plan. Investment in pre-pay solutions is growing twice as fast as the traditional model, at a 26% CAGR compared to 13% for post-pay.

The industry has recognized what the best health plans already know: intervening before adjudication is where the real impact lives. If your vendor is still leading with a pay-first approach while the market moves toward proactive, integrated payment oversight, your program is already behind.

Many health plans are managing relationships with 3 to 7 vendors for payment integrity alone, creating unnecessary complexity, siloed insights, and accountability gaps that are nearly impossible to close. Sound familiar?

The Cost of Staying Put

We understand hesitation. Evaluating a new vendor means navigating contracts, existing relationships, and the very real weight of organizational change. That’s not a small ask. But it’s worth weighing that against something that’s easy to overlook: the steady, compounding cost of a program that isn’t stopping errors before they happen.

Claims that pay incorrectly don’t just create financial exposure, they set a new baseline. Members bear the downstream impact of billing errors that should have been caught before adjudication, and a fee structure that looked reasonable at the outset can quietly erode the value of every dollar your vendor was supposed to protect in the first place.

If “good enough” has become the expectation, it may be time to recalibrate what a truly proactive program could actually deliver.

What a Clean Slate Looks Like

ClaimInsight, the Payment Integrity solution of AMPS, was built around a simple premise: payment integrity should stop errors before they happen, not clean them up after the fact.

That starts with Intelligent Policy Update (IPU), which layers accuracy across your entire claims stream, every claim, regardless of size or type, reducing leakage without adding friction. Built on that foundation is High-Dollar Review (HDR), which applies clinical and billing expertise before large claims adjudicate, catching errors at the point where intervention has the most impact. Together, they form an integrated pre-payment defense across your full book of business, not a patchwork of disconnected point vendors.

It means transparent methodology

you understand exactly how savings are identified, what the findings mean, and how they’re calculated. No black boxes. No surprises.

It means aligned incentives

a model structured to maximize outcomes for your plan, not to optimize our margins.

And it means a real partnership

where you don’t have to wonder what you’re getting, because the reporting is clear, the communication is consistent, and the results are defensible.

Ask your current vendor the same questions. Their answers will tell you everything you need to know.

And unlike fragmented point solutions, ClaimInsight never loses sight of the member. Proactive advocacy and balance-bill support are built in because savings that hurt the member aren’t savings at all.

May Is a Good Time to Look

Contracts renew. Plan years shift. Budget cycles reset. If your current payment integrity program is coming up for review, or should be, there is no better moment to explore what a more proactive, integrated approach could deliver.

Healthcare leaders are under growing pressure to show tangible return on payment integrity investments. The question is whether your current partner is equipped to help you meet it, or whether it’s time to find one that is.

Let’s talk about what’s getting through that shouldn’t.

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 or www.ClaimInsight.com.

The editorial staff had no role in this post's creation.