From Data to Decisions: A Conversation with Tom Baggett, Senior Director of Operations

Helping Health Plans Turn Payment Integrity KPIs into Action: Q&A with Tom Baggett

Amanda Bair: You’ve spent a lot of time in health plan data, especially through the payment integrity benchmarking report. What’s one finding that genuinely surprised you—and what should leaders do differently because of it?

Tom Baggett: The finding that stood out most is the disparity in how health plans use concepts. Everyone uses them, but when you compare more mature payment integrity programs to less mature ones, the difference is significant.

The mature programs are both broad and deep. They have strong coverage across many areas, and within those areas, they’re deploying a meaningful number of concepts to really dig into what’s happening in their data. I expected that gap to be narrower, but even when you account for health plan size, the disparity is still there.

The takeaway for leaders is clear: invest in both coverage and depth. There’s real competitive value in understanding not just what you’re measuring, but what you might be missing entirely.

AB: What’s driving that gap between more and less mature programs?

TB: Funding and resources are a major factor. Larger health plans have more capital to invest in their payment integrity programs, and that advantage shows up directly in how robust their concept coverage is.

But smaller or less mature plans aren’t stuck. They just have to be strategic about how they close the gap. One of the most effective levers is building industry connections. Attend conferences, network, and have real conversations with peers. Ask direct questions: “How is this concept performing for you?” or “How many people do you have working on it?”

That’s how good ideas spread. You don’t need to reinvent everything. You just need to stay curious, stay connected, and be willing to apply what’s working elsewhere to your own program.

AB: When you evaluate a health plan’s program, what signals tell you whether it’s truly effective — or just busy? 

TB: The number one indicator is whether the work is happening in silos.

If you’ve got one person working in spreadsheets, another in an Access database, someone else running SQL queries — everyone may look busy, but the work is fragmented. Even with strong communication, things get missed. Opportunities fall through the gaps because there’s no shared, unified view.

The more mature programs have moved past that. They’ve built a single source of truth — a centralized data environment where everyone pulls from the same place. That eliminates inconsistencies and allows the team to operate as one cohesive unit rather than disconnected parts.

So it’s not about effort. It’s about alignment.

AB: You lead client success and support. What does “great” look like in those areas?

TB: On the support side, great looks like fewer tickets but higher-value ones. We want the questions that require real thinking. Things like, “Why are these numbers different across two parts of the system?” or “Help me reconcile this discrepancy.”

Those are meaningful because they tie directly to how the business operates.

At the same time, we’re focused on what we call ticket prevention. That’s where our customer success managers engage proactively, working with clients to solve problems before they ever become support issues.

And then there’s the consultative side. Great means going beyond delivering data and actually helping clients understand what it means. It’s sitting down and saying, “I see something here — let’s dig into it together.” That’s where the real partnership begins.

AB: Where do payment integrity leaders get stuck most often when trying to transform their operations?

TB: They get stuck in reactive mode, spending a disproportionate amount of time trying to resolve problems after they’ve already surfaced.

They find an issue, and then they’re digging, digging, digging to get to the bottom of it. Meanwhile, everything else slows down.

Our goal is to help them get to the bottom line faster. So they can spend less time reacting and more time anticipating. I always say, you don’t want to drive by looking in the rearview mirror. You need to be looking through the windshield.

Transformation happens when you shift from reacting to anticipating.

AB: You talk a lot about insight and interpretation. What kind of reactions do you typically see from payment integrity leaders when you assess their program data?

TB: People often expect the “aha” moment. And, yes, that’s gratifying. But it’s not the most valuable reaction.

The most valuable reaction is, “No way—that can’t be right.” That’s when you know you’ve engaged someone. They want to challenge the data, push back on it, and understand what’s really driving it.

That tension is productive. It leads to better questions, better conversations, and ultimately better decisions. Like one of my former CFOs used to say, “It’s like a grain of sand in an oyster. That friction is what creates the pearl.”

AB: What shaped your approach to this work? 

TB: It’s a combination of things that reinforced each other over time.

I’ve always had a curiosity about what’s actually going on underneath the numbers. Pair that with a passion for data visualization — taking complex information and making it genuinely accessible — and then layering in the ability to have clear, human conversations about it.

My background in accounting also plays a significant role. Early in my career, I started viewing healthcare claims as one massive accounts payable problem. Once you standardize and normalize that data, you remove a lot of the noise and can focus on what actually matters.

That perspective has carried through everything I do.

AB: What do you wish payment integrity leaders better understood about maximizing value from their data and systems?

TB: Honestly, I think many payment integrity leaders — even those who are leveraging Pareo® — are underestimating the opportunity right in front of them.

There’s still substantial untapped value in understanding how different payment integrity functions interact with each other. When everything is consolidated into one platform, those relationships become visible in ways they simply can’t be otherwise.

That’s when the insights become actionable. You might see that performance in one area is declining while another should be compensating, and that immediately tells you where to focus.

The goal is simple: create a single, unified view of your program so you can truly understand what’s happening — and act on it.

Because at the end of the day, the data will show you the smoke. The real value comes from knowing exactly where to find the fire.

Conclusion

For Tom Baggett, the path to stronger payment integrity programs isn’t about chasing more data. It’s about asking better questions of the data you already have. The difference between average and high-performing organizations, he argues, comes down to clarity: a clear view of operations, a clear understanding of what the numbers actually mean, and a clear strategy for acting on them.

That clarity doesn’t happen by accident. It requires breaking down silos, creating a unified source of truth, and embracing the kind of productive tension that pushes teams to dig deeper rather than settle for surface-level answers. Most importantly, it requires a shift in mindset: from reactive problem-solving to proactive, insight-driven decision-making.

In a space as complex and fast-moving as payment integrity, that shift can be transformative. And as Baggett’s work continues to show, the organizations that get it right won’t just be better at measuring performance. They’ll be better at improving it.