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A blueprint for the next era in healthcare payment integrity | Viewpoint

Opinion
Article

AI and prepayment claims editing play a critical role in enhancing payment accuracy and unlocking value for health plans.

Today, healthcare generates approximately 30% of the world’s data – a figure that is expected to hit 36% by 2025.

Image submitted by author

Gene German

Meanwhile, healthcare payment integrity is undergoing a significant transformation, driven by explosive growth in AI, predictive analytics, and large language models (LLMs), as well as the evolution of payment tied to value-based care. These two key related developments are poised to revolutionize the payment integrity landscape. More data and better technology to utilize that data to improve the healthcare industry go hand in hand.

AI and prepayment claims editing play a crucial role in enhancing payment accuracy and unlocking value for health plans by improving medical savings, reducing administrative costs, connecting industry-sourced and evidence-based rules and policies to claims adjudication, and lessening provider abrasion. This works across all types of claims, including nuanced areas relating to precision medicine and rare diseases.

These powerful tools enable health plans to proactively identify and address issues early in the claims process, minimizing the need for costly and time-consuming post-payment interventions.

Payment accuracy challenges

Health plans continue to grapple with the persistent rise in healthcare costs, further exacerbated by the pent-up demand for services in the post-COVID era, administrative waste, as well as fraud and abuse. Many health plans are hindered by aging legacy systems and limited IT resources, making it difficult to prioritize and implement new payment integrity solutions.

Meanwhile, the payment integrity field is growing in scope and complexity –– with the market currently estimated at $9 billion and growing at a 7% CAGR in recent years, reflecting overall growth in U.S. healthcare spending and the ongoing complexity in billing processes. In such a dynamic and competitive market, it can be challenging for health plans to effectively evaluate and select the most appropriate options.

Furthermore, payers often struggle with centralizing payment integrity that is fragmented among multiple departments and vendors –– leading to suboptimal results and increased administrative burden.

Here, AI is exceptionally well positioned to emerge as a change agent to facilitate, streamline, and improve payment accuracy operations. By utilizing the abundance of healthcare data—held by stakeholders—AI and predictive analytics enable the development of innovative solutions that address a wide range of challenges across the payment integrity value chain.

AI-powered platforms and solutions can tackle both traditional pain points, such as fraud, waste, and abuse, as well as emerging challenges, like the rapid growth in claims related to genetic testing and the complexities of specialty pharmaceuticals.

By leveraging AI, payers are able to move pre- and post-payment integrity capabilities to placement earlier in the claims process — improving speed of detection, reduced administrative costs, reducing provider abrasion. Early intervention through the prepay editing process minimizes the need for post-payment reversals and claims rework, leading to lower administrative costs and improved payer-provider relationships.

Moreover, the increasing accessibility and affordability of AI technologies are democratizing the development of payment integrity solutions, enabling smaller, more specialized players to enter the market and drive innovation. There is also a strong likelihood that plan members will have greater access, understanding, and actionability in their care choices and shopping through improved tools involving price transparency.

Collaboration and co-creation key to product development

Successful solution development in the payment integrity space hinges on specific industry experience as well as fostering deep, long-lasting relationships with health plan customers to gain a thorough understanding of their unique challenges and pain points.

By collaborating, not as vendors but true ally partners with payers, solution providers can develop targeted offerings that address specific, real-world challenges, such as state Medicaid compliance or the administrative burden associated with genetic testing claims.

While no single vendor can excel in every area of payment integrity, leaders recognize the importance of utilizing AI, predictive analytics, and best-in-class capabilities through a platform vs. a point solution strategy. Flexible, modular payment integrity platforms are essential for enabling health plans to coordinate data, operations, and unlock value through optimal performance.

In the new era of payment integrity, the role of AI transcends merely automating tasks; it's about augmenting the human expertise and decision-making prowess within the healthcare sector.

By seamlessly integrating into the workflows of healthcare professionals and administrative staff across payer and provider landscapes, AI serves to amplify their capabilities.

By adopting AI, advanced analytics, and other transformative technologies into product development, automation of routine tasks and the analysis of complex, vast datasets will continue to empower provider and health plan professionals to dedicate more of their invaluable time to patient care, care management, and other strategic, high-priority tasks and processes.

This paradigm shift enables a more focused approach to healthcare delivery and administration, underpinning the transformative potential of AI in driving efficiency and enhancing care quality without supplanting the irreplaceable human touch.

The future of payment integrity

Looking ahead, payment integrity will be characterized by an ongoing shift towards prepay solutions and "moving to the left," with AI-powered interventions being deployed earlier in the claims lifecycle to maximize impact and minimize downstream costs.

The payment integrity landscape will continue to evolve, with the emergence of highly specialized, AI-driven solutions from a diverse range of players, including innovative startups and niche experts.

As the number and complexity of payment integrity solutions grows, the adoption of platform-based approaches will become increasingly critical, enabling health plans to efficiently integrate and model the impact of diverse and well-aligned capabilities.

Successful payment integrity solution providers will prioritize flexibility and customer-centricity in their product design and deployment strategies, ensuring that their offerings can be seamlessly adapted to the unique needs and constraints of each health plan.

The advent of advanced Large Language Models holds immense potential for revolutionizing payment integrity and patient engagement, enabling more natural, intuitive interactions and unlocking new possibilities for personalized support and decision-making.

The convergence of AI and prepay editing solutions represents a transformative force in healthcare payment integrity, driving unprecedented levels of accuracy, value creation, and transparency across the healthcare ecosystem.

As the payment integrity landscape continues to evolve, technology partners will play an increasingly vital role as allies to all healthcare stakeholders – from payers to providers to patients – simplifying the business of care and enabling a more efficient, effective, and equitable healthcare system for all.

Gene German serves as Lyric's chief product and technology officer.


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