Find what’s causing your health plan’s overpayments

Forward-thinking health plans put payment integrity (PI) high on their priority list. Uncovering the root causes of overpayments through effective PI saves valuable claim dollars, improves provider relationships, and eases administrative burdens on your staff.

How can you stop errors at their source, reduce friction, and improve your plan’s performance? Learn exactly what you should — and shouldn’t — expect from a high-performing partner.


Choose the right payment integrity partner

This is the most important step. The right partner makes all the difference.

To effectively recover, eliminate, and prevent provider overpayments, your PI partner must be collaborative. Only through clear, ongoing communication with your team can an approach be developed that will address your pain points and meet your ongoing objectives.

Transparency is a fundamental building block of effective PI. Be wary of vendors who block you from seeing what goes on behind the operational curtain. Your plan can’t put a stop to consistent overpayments if you don’t know what’s causing them. No health plan wants to keep paying fees for errors that can be identified and corrected.

Practicing a high degree of transparency builds trust. Everyone benefits from better payer and provider relationships as well as the smooth, swift, and accurate payment of claims. Getting it right the first time is a result of true collaboration.

Know the key causes of overpayments — and respond. Ask your payment integrity vendor:

  1. What concepts are trending downward and underperforming? They may need to be recalibrated.
  2. Which providers consistently bill incorrectly? They likely need some assistance and education to get them on the right path.

A high-performing PI partner will identify the root causes of overpayments, discuss them with you openly, and help you correct problem areas.


Yesterday’s approaches to payment integrity are no longer as effective as they once were due to increasing healthcare complexity. Vendors who only offer a static catalog of standard overpayment concepts will miss a significant number of leads.

Leveraging your plan’s unique insights will drive more recoveries. Only by consistently assessing your plan’s specific PI program performance levels and pivoting when needed can overpayments be caught. A high-performing PI partner will always keep a close eye on your company’s unique issues and jump in quickly to address them.

Use real-time reporting

Today’s technology and advanced analytics can make a powerful difference in your PI results. Comprehensive dashboards and on-demand reporting can:

  • Measure the results of data mining and other value streams.
  • Show the value of overall programs like coordination of benefits.
  • Find what’s underperforming and trending down.
  • Drill down to show details such as total program, concept, or even associate-level performance.
  • Enable you to respond quickly to errors.

Once issues and patterns are identified, simple actions can have a strong, cumulative effect on your provider relationships, recoveries, and savings. This is why transparency is so critical.

Treat the root causes — not just the symptoms

When it comes to PI, recovery is good, prepay is better, but prevention is best. The health of the healthcare system improves when spending is responsible and accurate.

For high-performance payment integrity, you need a high-performing partner. If your current PI vendor isn’t transparent about their strategy or taking a tailored approach to meeting your needs, it might be time to search for something new.

Carelon Insights is making payment integrity more efficient and proactive than ever before. Contact us to learn more about the possibilities and impact of our Payment Integrity program.


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