How to Build a Business Case for a Payment Integrity Platform

A step-by-step framework for PI leaders to build consensus and get executive buy-in on their tech-forward vision for the future

Making the case for an enterprise payment integrity technology platform can be challenging because the return on investment is more complex than “immediate savings.” Given the significant capital involved, PI leaders must build consensus across finance, IT, compliance, procurement, and executive leadership, each of which has different priorities, concerns, and success metrics.

That complexity means success depends on more than demonstrating that a platform can improve operations. Numbers like a 10% increase in overpayment recoveries or an 80% reduction in time spent on reporting may look impressive, but without context, they can be hard to envision or even believe.

Overcoming these barriers and getting decision-makers on board requires presenting a structured business case. This is a written document and/or slide presentation that clearly defines a problem, suggests a solution, evaluates alternatives, quantifies financial impact, and demonstrates how the investment in the chosen solution supports broader organizational goals—using the organization’s own data.

“When you push yourself to assess where you stand, you also start figuring out that vision of the future, which gives you a great platform to get needed buy-in. Executive leaders will be very interested in what potential results you foresee.”

— VP of Business Operations, Medicaid MCO

How to Complete the Platform Business Case Framework

Start with the Project Overview

Every business case begins with a short overview that establishes accountability and processes from the outset. It should include the project title, business case owner, key contributors (payment integrity, finance, IT, etc.), the expected path for governance and approvals, and a concise statement describing the project’s objective.

These details support visibility and understanding of who owns the initiative, who contributed to the analysis, and how decisions will move through the organization.

Write the Executive Summary

Although it appears near the beginning of the document, the executive summary should be completed near the end of the project, after the team has developed the business case. It should distill the case into a scannable overview using a simple Situation-Complication-Solution format.

Include a table showing the current state vs. the expected state for the top three to five metrics to be assessed, the recommended action, requested approval, and the ROI. This at-a-glance summary provides stakeholders with a high-level snapshot to entice them to keep reading.

Provide Context on Background and Current State

In this section, you’ll show why the status quo is no longer acceptable. This should include a brief overview of current PI operations, existing technologies or processes and their limitations, and staffing capacity and constraints. Make sure to outline key pain points with supporting data when available. These might include:

• • Fragmented vendor management that requires toggling between different platforms, spreadsheets, and emails
  • Limited visibility for analysis and reporting, requiring manual compilation
  • Increased risk of write-offs due to SLA oversights or uncoordinated audits
  • Where time-consuming and labor-intensive manual workarounds are required

The goal is to establish why maintaining the current approach has or will become increasingly expensive and difficult to scale.

Quantify the Problem

This is arguably the most important section of the entire business case. Reading about the size and impact of the problem is one thing. Seeing it in hard numbers is another. Internal data is most effective here, but if that isn’t available, ranges from Pareo® benchmarks can serve as reasonable assumptions. Focus on issues like:

• • Hours wasted on manual tasks
  • Financial exposure due to write-offs, duplicate audits, and unrecovered overpayments
  • The costs related to the inability to bring processes in-house, expand pre-pay operations, or show ROI to leadership
  • The risks of not taking action to modernize and unify systems, such as failure to align with compliance requirements, losing employees, or an inability to incorporate AI initiatives in the future

Present the Solution in Context

You’ve outlined the problem in detail, with data to back it up. Now it’s time to present the solution.

Provide a brief description of Pareo as an enterprise payment integrity operating platform designed to unify payment integrity operations, not another vendor or standalone solution. Instead of listing every feature, map capabilities directly to the challenges listed previously. For example, organizations struggling with fragmented workflows may prioritize audit inventory and vendor management capabilities, while those looking for enhanced visibility may focus on insights and reporting.

Because executives are often wary of lengthy implementations that cause disruption and confusion, show how Pareo takes a phased approach to rollout, emphasizes speed to value, connects to existing systems with simple file-based integrations, and works alongside existing vendors, teams, and workflows instead of replacing them.

Options Analysis

A simple comparison helps decision-makers see why one option delivers greater value over the long term than the others and supports a strong business case. A table can show the costs, timeline, risk, capabilities, and scalability of each option at a glance.

• • Option A: Maintain current systems/processes. Quantify the ongoing cost of doing nothing (FTE time, write-off exposure, vendor fees paid without visibility).
  • Option B: Building a solution internally. Estimate the timeline (typically three to four years or more based on comparable plans), resource requirements, ongoing maintenance burden, and capability gaps vs. commercial solution.
  • Option C: Pareo as the recommended option. Include the implementation timeline, go-live capabilities, total cost of ownership.
  • Option D: Any other solutions under consideration.

“We invested 5 years and $12 million in developing a custom software solution — and it still wasn’t usable.”

– CEO, National Health Plan

Build a Financial Case for Pareo

Every financial assumption included in the business case for Pareo should have a documented source, either internal data (which carry more weight than vendor estimates) or Pareo benchmarks.

Quantify expected benefits alongside operational improvements while balancing them against total implementation costs. Provide a summary table that includes projected benefits vs. costs, payback period, and any financial measures preferred by your finance team, such as net present value or internal rate of return.

The Pareo ROI Calculator can help you build an evidence-based financial analysis using your own operational data.

Show Strategic Alignment

Even projects with compelling ROI compete for limited capital or other important initiatives. In this section, show decision-makers how the proposed investment aligns with organizational priorities, goals, and annual PI program targets. This helps position the platform as enterprise infrastructure that enables long-term operational improvement, not just another service or tool purchase.

Risks and Mitigation

Show the risks of implementation (such as a lack of IT resources or budget cycle timing) in a table along with their likelihood, their impact, and mitigation strategies.. Don’t forget to demonstrate the risks of not proceeding and maintaining the status quo.

Implementation Plan

Break down implementation into high-level phases and estimate the timeline for each phase. Include key milestones and decision gates, as well as internal resource requirements by function and where Pareo can step in to provide support. Finally, anticipate potential components that may be out of scope or may need to be pushed out to a second implementation stage.

Governance and Monitoring

Outline who will be responsible for overseeing implementation, such as the project sponsor, project manager, and ClarisHealth implementation lead. Define the reporting cadence for implementation efforts and develop a post-go-live plan to track KPIs.

Approvals and Next Steps

Create a signature block for sign-off with descriptions of responsibilities. Outline recommended next steps if the implementation is approved and detail any considerations during the contracting timeline, such as alignment with budget cycles.

Appendix

Attach or link to additional documents, such as a financial workbook or ROI model, a vendor evaluation scorecard (if applicable), a compliance and security overview (such as HITRUST, SOC II Type 2, HIPAA), and client references or social proof.

A Framework for Decision-Making

Building a payment integrity platform business case requires creating a shared understanding of the operational challenges, financial impact, implementation approach, and long-term strategic value across multiple stakeholders.

A structured framework makes that process easier. By documenting each section and providing sound evidence, payment integrity leaders can spend less time reworking presentations for different audiences and more time cultivating organizational alignment.

You can customize this editable template with your own organizational data, priorities, and financial assumptions as you build the case for enterprise payment integrity technology.

Talk to ClarisHealth about how we can support you in making your business case for the Pareo payment integrity operations platform.