In an industry that has struggled to quickly and meaningfully address healthcare claims payment accuracy, digital transformation once again proves its value. How can payers best take advantage of the potential of enterprise technology?
Enterprise payment integrity technology creates efficiencies that improve claims overpayment identifications and recoveries year-over-year, according to an internal study conducted by ClarisHealth business insights analysts. The study shows that payers that use integrated advanced technology recover overpayments 50% faster, increase recoveries 31%, and increase identifications 21% after the first year of platform adoption.
The findings surpassed the anticipated efficiencies and increases that were projected for early performance and demonstrate the potential of enabling technology to rapidly improve healthcare payment accuracy.
The study looked at key performance insights across payers that had used the company’s proprietary platform Pareo® for several years, comparing year-one to year-two results. These impacts translate to tens of millions in increased recoveries alone. A significant improvement in an industry that has struggled to quickly and meaningfully address healthcare claims payment accuracy.
The Scope of the Healthcare Overpayments Challenge
The U.S. has normalized a healthcare system known for waste. The seminal 2019 JAMA report pegs the estimated annual cost at $760 billion to $935 billion, or 25% of total healthcare spending. At the same time, the projected potential savings specific to payment integrity are at least $80 billion.
Healthcare represents around 20% of GDP, with more than half flowing through payers. With rising healthcare costs one of the leading contributors to inflation, the time is now to make a change. Change that signals the ability to enterprise technology to introduce transparency into opaque and complex processes — both within and outside of the enterprise. Payers that take advantage of these new technologies have the opportunity to reposition themselves at the center of the healthcare landscape.
How Payers Approach the Shifting Role of Payment Integrity
Payers understand the scope of the challenge as well as the potential positive impacts of addressing those. But significant barriers to growth and progress still exist.
A 2020 industry report noted that “complex legacy systems and issues with data, governance and culture” could pose challenges to innovation taking hold among health insurers. An informal survey of payment integrity leaders conducted by ClarisHealth in 2022 surfaced several interesting insights that corroborate those findings:
- More than half of participating leaders (56%) describe their payment integrity organizations’ current maturity level as “developing” or “limited.”
- The majority (83%) cited access to staffing, analytics or process management technology as their top challenges to maturing this approach.
In payer organizations where payment integrity is still and emerging and developing domain, excessive provider abrasion and less-than-optimal medical savings are the norm. but within this environment of resource constraints and mandates to address healthcare waste, there exists tremendous upside for solutions with proven results. Especially ones that meet payers at various stages of maturity and according to individualized strategies.