5 questions you should ask your payment integrity vendor

The right payment integrity partner makes a difference

Transparency and accuracy are essential to effective payment integrity (PI). When done correctly, PI builds trust with providers and members. Everyone benefits from better payer and provider relationships as well as the smooth, swift, and accurate payment of claims.

Getting coordination of benefits (COB) right the first time matters. It eliminates the need for members and providers to dial into your call center asking why the claim hasn't been paid yet and doesn’t require providers and your team to do time-consuming — and expensive — rework to determine correct payer order.

As a health plan, your choice in a payment integrity vendor can affect not only your bottom line, but whether providers and members can rely on your plan.

Is your current PI vendor helping or hurting your relationships with members and providers? Ask them these five questions to find out.

1. How many COB-related overpayments are you finding?

Your health plan may be wasting money through poorly executed COB. Industry estimates show that manual COB processes may only catch around 10% to 20% of overpayments. At Carelon, we catch 60% to 70% of overpayments. Our automation and streamlined processes result in high accuracy rates — which positively affect provider and member relationships.

The more validated overpayment leads your PI vendor finds, the more opportunities your plan has to correct membership statuses and stop overpaying on claims. This saves money and improves member and provider experiences. Your PI vendor should be able to tell you:

  • What they're doing to decrease the average timeframe of recovered claims.
  • What they’re doing to proactively ensure your plan’s membership files are current and correct.
  • How they determine the responsible primary payer.

Strong data mining, industry-wide eligibility data channels, and a strong analytics platform lead to more satisfied members and providers.


2. How are you helping us minimize COB rework for our plan and for providers?

When payer order isn’t determined correctly, there’s a lot of rework to be done — pulling your team and providers away from other pressing projects and initiatives. Rework can mean additional administrative burdens such as resending information, correcting coding errors, or updating patient information. This leads to delays in claim settlements and unhappy members, providers, and payers.

Through automation, we deliver consistent, clear, and irrefutable payer order — the first time around. That way COB becomes more predictable and understandable for all.

3. Are you using automation to accelerate manual processes?

Automation is no longer nice to have, it’s a must-have in today’s COB landscape. If you or your PI vendor are still reviewing leads one-by-one to spot incorrect primacy determinations, it’s time to pivot to a new strategy.

Not all leads are viable or worth pursuing. What if you only had to focus on the ones that were primed to deliver value? Think of all the time and manpower that would save. Additionally, automation leads to standardization and eliminates opportunities for human error. Our solution enters your plan into the automated era. We provide your team with a list of leads reflecting members having more than one insurance coverage. Leads are prioritized by value and other considerations — such as their recovery expiration date.

Data shows that our automation reduces manual COB work by 60%.

4. How are you handling particularly complex leads?

While automation is crucial, it can’t solve every problem. For leads that are too complex for automation, do they have the necessary expertise, processes, and resources to look at the case from every angle and make an accurate payer order determination?

At Carelon, our subject matter experts have decades of experience. We’re able to help you dig deep and uncover the nuances of every complex lead. Having all the facts will help you make a more well-informed decision about payment order. We share our findings through a collaborative, online workflow tool. Better, more accurate decisions lead to clarity for providers and plans.

5. How are you helping us cultivate better experiences with providers?

Creating a well-operated and accurate COB claim payment program ensures timely, appropriate payments to providers — which fosters members' trust in your plan. Preventing incorrect payments in the first place or quickly and accurately identifying overpayments leads to provider respect. Trust and respect are everything in healthcare.

The best way to control costs and smooth tensions between providers, payers, and members is to ensure the correct plan is paying the right amount at the right time.

Ready to make a change?

At Carelon Payment Integrity, we’re making PI more efficient and effective than ever before. Contact us to discover what we can achieve together.

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