Healthcare’s Payment Integrity Trends: How the Landscape Has Changed

In recent years, payment integrity has become something of a buzzword in the healthcare industry. The buzz is due, in part, to an overall increase in healthcare costs, which professional services firm Aon expects to further increase by nearly 7% in 2023. The outrageous number of erroneous healthcare payments serves as the main systemic force fueling bloated health plan costs. The same issue sparks widespread interest in payment integrity practices.

Payment integrity drives effective cost containment solutions in healthcare by identifying errors, duplicates, and inconsistencies that patients would otherwise have paid. In addition to verifying accuracy, payment integrity strives to prevent abusive billing practices in the future.

Given the alarming frequency at which billing errors occur, any large claim could benefit from a line item review. In his April 2022 article for Employee Benefit News, Keith McNeil points out that no less an authority than “the Journal for the American Medical Association confirms that upwards of 20% of all healthcare spending in the U.S. should be classified as fraud, waste, and abuse.” 

Recent federal laws—The Hospital Price Transparency rule of 2021, the No Surprises Act of 2022, and the Transparency in Coverage Final Rule—help protect patients from such unethical billing practices. All require greater price transparency from providers, which could prompt employers and administrators to increase claim reviews and verify billing procedures. In alignment with these laws, payment integrity functions like a system of checks and balances to help lower costs, waste, and abuse while adding clarity and transparency to the healthcare reimbursement process. 

It’s no surprise that a practice like payment integrity is shaking up the healthcare landscape. For an industry that depends on cutting-edge scientific research, the healthcare profession remains surprisingly rooted in tradition. In stark contrast, payment integrity values accountability above tradition.

The healthcare power dynamic has favored providers over patients so heavily for so long that even small administrative changes may seem like radical upheaval. Far from revolutionary, payment integrity simply endeavors to shift the balance of power back to a semblance of equity. 

But how did payment integrity start? Where is it headed? Learning about payment integrity trends can help you stay informed about the ever-evolving healthcare industry.

History of Payment Integrity in Healthcare

Payment integrity has been around for the better part of two decades. While it once existed as a way to recuperate losses after claims had been paid, it has adapted over time to become a significant part of proactive healthcare operations. 

Although payment integrity was once considered a “niche practice” with smaller scale operations, it has since grown to encompass complex strategies and an array of specific activities:

• Hospital bill audits
• Data mining
• Diagnosis-Related Group (DRG) validation
• Code edits

Now, payment integrity focuses on pre-payment strategies to lower claims before patients reimburse a provider. Due to the efficacy with which it contains healthcare costs, payment integrity has become more widely adopted within the field. Some even see it as an illustration of healthcare’s potential new reality.

Even with the obstacles payment integrity faces, like the complex coding guidelines that remain in continual flux, it can still add significant value to company operations by cutting down on wasteful spending and abusive billing practices. 

Healthcare Payment Integrity Trends

Many factors are driving a shift in healthcare and changing the way payment integrity is implemented. These are some of the most pertinent payment integrity trends shaping the healthcare industry’s future.

Vendor Consolidation = Less Competition

Historically, plan administrators have outsourced claims adjustment to third-party vendors. Many such vendors offer expertise during the adjustment period and play a crucial part in the payment integrity process. 

While many past claim adjusters worked for smaller organizations, larger vendors and venture capital groups have recently purchased many of these smaller operations. Although this kind of consolidation can streamline operations to some extent, it also limits options that could impair potential price negotiation.

However, new mergers could also broaden opportunities for payment integrity practices. By using smaller vendors in conjunction with larger vendors, businesses can maximize the capabilities of both in a vendor mix. Larger vendors often have access to a broader range of plan options while smaller vendors can offer specific areas of expertise and niche products.

Regulatory Changes 

As technology progresses, data privacy and security laws have also adapted. These digital issues also affect the healthcare reimbursement process with characteristic complexity and greater scope. Factors contributing to these changes include, but are not limited to:

• Changes in Centers for Medicare Services (CMS) guidelines
• Role of the Affordable Care Act (ACA) and potential changes
• Price transparency mandates

As such, health plans must update according to regulatory guidelines to retain the satisfaction of providers and patients, and must also meet government regulatory compliance standards. Such increased regulation requires software solutions to ensure payment integrity compliance, monitor efficiency levels, and make adjustments as needed.

Technological Tools 

Because of the various factors influencing payment integrity, more PI vendors have come to rely on existing and emerging technologies such as artificial intelligence, machine learning, and electronic medical records. 

The variety and availability of cloud services testify to their increasing popularity. Cloud-based systems can meet increasing demands for efficiency in ways legacy systems cannot. When supplemented by AI and machine learning algorithms, cloud services have the capacity to process much larger volumes of data while making real-time insights, tracking data patterns, and offering quick, easy access to information.

Payment integrity processes can benefit significantly from such advanced technology by making existing resources more cost-effective and increasing accuracy and efficiency for claims adjustment and clinical reviews.

6 Degrees Health for the Future of Payment Integrity

6 Degrees Health is an industry leader in payment integrity. Our organization was founded by healthcare experts to solve the problem of increasingly unreasonable healthcare costs. Our Clean Claim Review process is far more than a typical clinical review. It evaluates every line item billed to accurately identify inconsistencies that patients don’t need to pay. 

Backed by our sophisticated MediVI software and reference-based pricing model, our Clean Claim Reviews are an effective cost-containment solution that can keep you current with healthcare payment integrity trends.

Want to know more about healthcare payment integrity trends? Speak to a representative today to find out how to file a claim. Our payment integrity practices can help you save big and realize the true benefits of healthcare.