At AMPS, we believe the future of payment integrity hinges on addressing the "payer paradox" — the complex balancing act between controlling costs and ensuring accuracy in claims management. Recently, we hosted a thought-provoking fireside chat, "Unmasking the Payer Paradox: Transparency, Trust, and the Future of Payment Integrity," where industry experts Mark Noel, PMP, Senior Vice President and General Manager of ClaimInsight, and Patricia Howard, Founder and CEO of C Suite Assets, shared their perspectives on the challenges and opportunities within the payment integrity landscape. Here's a debrief of the key takeaways.
The Payer Paradox: Outdated Systems and the Need for Innovation
The healthcare industry has long been a laggard when it comes to technological innovation, and payment integrity is no exception. As Patricia Howard explained, outdated IT systems, regulatory hurdles, and fragmentation within the healthcare ecosystem have slowed down transformation. Despite these barriers, the pressure to reduce costs and improve accuracy is now forcing change. Both payers and providers are recognizing the need for smarter, more efficient solutions that eliminate the hidden costs, errors, and waste embedded in the system.
Moving Beyond Contingency-Based Payment Integrity Solutions
The traditional contingency-based model, where payment integrity solutions are compensated based on the savings they recover, has been a mainstay in the industry. However, as Mark Noel noted, this model can be costly and unpredictable. At AMPS, ClaimInsight, we're exploring alternative models like fixed-fee and PMPM (per member per month) solutions, which allow for more control and transparency in costs. These models align more closely with the needs of payers who are seeking value, accuracy, and a true partnership approach rather than a transaction-based relationship.
Proactive Cost Savings: The Role of Real-Time Analytics
Traditionally, payment integrity efforts have focused on retrospective reviews — looking back to identify overpayments or errors. Mark highlighted the growing interest in proactive solutions that leverage advanced analytics and real-time insights. By identifying cost-saving opportunities before payments are made, payers can prevent waste and make more informed decisions. AMPS ClaimInsight's approach includes a range of payment integrity solutions that help move the industry toward prepay models, offering more control over the payment process and ensuring accuracy before claims are settled.
High-Dollar Claims: Deep Dive into Effective Review Processes
High-dollar claims are a significant area of concern for payers, representing a large portion of healthcare spending. Mark shared how ClaimInsight approaches these claims with a physician-led, deep-dive review process. By applying clinical judgment in addition to standard clinical edits, we ensure that claims are reviewed thoroughly, often uncovering opportunities for down coding and repricing that can save payers significant amounts. Furthermore, our flexible approach allows us to tailor our services to meet the specific needs of each client, including reviewing claims at lower thresholds than most vendors typically allow.
Building Transparency and Trust Between Payers and Providers
Transparency is often promised in the payment integrity space but rarely delivered. Patricia stressed the importance of building trust between payers and providers, which can only happen through open communication and collaboration. By sitting at the same table and identifying pain points on both sides, payers and providers can work together to create more integrated and effective solutions. This process involves not only resolving deficiencies within the payment process but also ensuring that all stakeholders — including providers and patients — are part of the solution.
The Future of Payment Integrity: A Partnership Approach
The future of payment integrity is shifting toward a more transparent, proactive, and collaborative model. As Mark and Patricia concluded, the industry is at a crossroads. Moving away from outdated contingency models and embracing innovative, AI-driven solutions will empower payers to gain greater control over costs and improve the accuracy of claims. But perhaps most importantly, building trust and transparency between payers and providers will be essential for creating a system that benefits everyone — payers, providers, and patients alike.
We invite you to join the conversation and learn how AMPS ClaimInsight is helping to shape the future of payment integrity. Stay tuned for more insights and updates on our approach to smarter, more transparent healthcare cost containment solutions.
Join us on the journey towards a more efficient and transparent healthcare system! Email us at claiminsight@amps.com
