As internal PI teams grow, vendor footprints expand, and savings targets rise, operational complexity can outpace control. Here’s how to recognize the tipping point — and what to do about it.
Search Results
Health Plan Operations
Have You Hit a Wall Scaling Your Payment Integrity Operation?
From Data to Decisions: A Conversation with Tom Baggett, Senior Director of Operations
This Q&A with Tom Baggett is part of our Innovators series. Tom reflects on payment integrity benchmarking, breaking down silos, and why the best insights don’t start with “aha” — they start with “no way.”
Report from the Field: Six Signals Reveal the Future of Payment Integrity
Payment integrity leaders from the country’s top health plans gathered at the Power of Payment Integrity Conference 2026. They found a community ready to take on today’s challenges and create tomorrow’s solutions.
AI in Payment Integrity: Why the Foundation Matters More Than the Algorithm
Payment integrity leaders are operating in one of the most challenging payer environments in over a decade. Those realizing the largest returns from AI are using best practices, which include ensuring AI is part of a broader closed loop system vs. used as a point solution.
People First, Always: A Conversation with Tara Dufrene, VP of Client Engagement
This Q&A with Tara Dufrene is part of our Innovators series. Tara reflects on a decades-long career helping payment integrity leaders turn strategy, technology, and trust into real results.
Engineering the Future of Payment Integrity: A Conversation with Alex Yanes, VP of Engineering
This Q&A with Alex Yanes is part of our Innovators series. Alex explains how empathy, security, and product thinking guide the technology powering modern payment integrity for health plans.
2026 Payment Integrity Technology Trends: The Shift From Savings Engine to Enterprise Control
What is on the horizon for healthcare payer technology in 2026? In this annual report, ClarisHealth and industry experts review the trending drivers – and associated opportunities – so health plans can innovate payment integrity while minimizing risk.
From Manual Muscle Memory to Modern Payment Integrity: A Conversation with Dana Ryan, Senior Manager Client Success
This Q&A with Dana Ryan is part of our Innovators series. Dana shares lessons learned from 20+ years helping health plans unlearn old processes, embrace automation, and see ROI from their PI programs.
Consistency Is the New Scalability: A Conversation with Stephanie Gibbons, Vice President Clinical Operations and Internal Audit Management
This Q&A with Steph Gibbons is part of our Innovators series. Steph breaks down the core principles driving her approach to transforming health plan operations including clinical nuance, operational discipline, and a deep respect for the work.
Health Plans Need a Tech-First Strategy to Navigate Today’s Consolidation Pressures
How payment integrity leaders can strengthen their plan—whether the goal is to attract the right partner or remain confidently independent.
Bridging Product, Data, and Operations: A Conversation with Chandler Wilson, Senior Product Owner
This Q&A with Chandler Wilson is part of our Innovators series. Her 15-years’ experience in payment integrity and healthcare technology brings insights into how aligning systems, people, and strategy in Pareo® helps health plans turn data complexity into operational clarity.
A Lifelong Advocate for Health Plans: A Conversation with Kimberly Fadden, SVP of Client Management
This Q&A with Kimberly Fadden, a 40-year healthcare technology leader, covers payment integrity, client advocacy, and navigating cost pressures with trust and transparency as part of our Innovators series.
Beyond Disruption: 5 Strategies Every Health Plan Needs for 2026
When industry disruption is constant, your strategy needs flexibility. Here’s what successful payment integrity leaders are doing now to prepare for 2026 and beyond.
Behind the Data: A Conversation with Quzonna Reed, Business Systems Analyst
This Q&A with Quzonna Reed, who has worked with ClarisHealth for over six years helping health plans transform their data to power smarter payment integrity with Pareo®, is part of our Innovators series.
Driving the Future of Payment Integrity: A Conversation with Tom Noack, SVP of Product Strategy
This Q&A with Tom Noack, who has deep roots in the community from years of hands-on experience leading PI teams at a top 10 payer – where he was instrumental in bringing on Pareo®is part of our Innovators series.
Reimagining Payment Integrity: How Health Plans Can Optimize Using a Modern Operating System Built for the Future
Are payment integrity strategies stuck in the past? This strategic brief explores 4 concepts health plans can use to update business models and optimize using a modern operating system built for the future.
Power of Payment Integrity Conference Reveals 5 Strategic Insights
Payment integrity leaders from the country’s top health plans came together for the Power of Payment Integrity Conference. They found strength in community, innovative ideas, and 5 powerful themes that will drive progress in the industry.
Managed Medicaid Plan Finds Technology Partner to Grow Payment Integrity Savings
Kern Health Systems selects Pareo® One technology-enabled payment integrity services to shore up claims accuracy efforts. Using an integrated, provider-first approach, ClarisHealth auditors identify $3M in first 9 months for the Medicaid MCO.
Buying payment integrity technology: 6 considerations
More health plans see the value in reducing administrative complexity to improve costs and payment accuracy. This step-by-step guide for payment integrity leaders buying enterprise technology ensures you reach those goals.
Payment Integrity Leaders Reveal What Will Move the Industry Forward
Payment integrity leaders from the country’s top health plans take time to collaborate at POP Conference 2024. They find strength in community, innovative ideas, and a focus on 4 primary industry drivers.
Improving Payment Integrity with a Building Blocks Methodology
Payers need a proven framework for payment integrity to create financial value, handle change, and engage at the highest levels of organizational strategy. This 5-step methodology works whether the directive is accelerating growth, building from scratch, or somewhere in between.
Will Artificial Intelligence Finally Make Good on its Promise to Healthcare?
Artificial Intelligence is making the leap from much-hyped “trend” for healthcare technology to more widespread adoption. Here’s what A.I. is — and isn’t — and how health plans are proving its value. Artificial Intelligence for healthcare has come a long way since...
Payers Reduce Administrative Costs by Going Back to Basics with Payment Integrity
In the face of economic and hiring constraints, payment integrity leaders are prioritizing these 4 best practices to shift to an enterprise strategy that offers proven value.
Health Plan Leaders Speak Out on Building the Payment Integrity Organization of Tomorrow
Whether or not health plan leaders implement a fully centralized PIO, sharing information on an enterprise payment integrity technology platform helps overcome challenges and meet strategic opportunity.
Study Reveals Payers Recover Overpayments 50% Faster with Enterprise Technology
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?
How Medicaid Managed Care Organizations Are Faring on Top 3 Issues
What can your Medicaid MCO do to prepare for this year and beyond? Medicaid managed care organizations are continually in a balancing act, facing tighter-than-average budgets, political pressures, and an evolving, uncertain healthcare landscape. The COVID-19 public...
Payment Integrity Leaders Ready For A New Normal
With the ever-changing outlook of the payment integrity industry, now is the time to get ahead by making strategic investments in change.
Vendor Consolidation Reduces Payment Integrity Innovation
What steps should your health plan take to ensure you get the most value from your services vendors and payment integrity efforts in the face of vendor consolidation?
The Strategic Approach to Claims Cost Containment
Competing with other health plan functions for technology priority can lead to missed audit claims cost savings potential. An integrated payment integrity strategy breaks down these internal silos. With so many moving – and vital – parts within a payer organization,...
How to Evaluate Payment Integrity Solutions: The Ultimate Guide for Health Plans
Payment integrity solutions vendors make many claims. Here are the top 11 areas of evaluation to ensure a perfect fit for your health plan. Virtually every health plan is looking to address shrinking margins by moving their medical savings from a typical 1-2% today to...
5 Reasons for Health Plans to Choose a Scalable Payment Integrity Technology Platform
Are you using an assortment of software tools to do work better suited to a platform? You might be missing out. When your health plan starts looking to upgrade your payment integrity and fraud management processes with technology, what do you turn to? A tool or a...
Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis
Coronavirus highlights power of big data and the need for interoperability to improve population health. How can health plans lead the way? What’s the single biggest weapon used by government, pharma, academic researchers, healthcare systems, and health insurers alike...
Your health plan’s best crisis response strategy? Innovation.
Health plans set themselves up for success – during a pandemic and beyond – by pursuing advanced technology to engage providers, satisfy members, and improve population health initiatives. The healthcare system is on the front lines of the novel Coronavirus pandemic,...
Try Before You Buy: A bottom-up approach to health plan technology adoption
Why flipping the script enterprise software is the future of digital transformation? Have you ever tried a piece of technology at your health plan before it was adopted by the broader organization? Think about solutions like MailChimp, Survey Monkey, Slack and...
Should Your Health Plan Build or Buy a Technology Solution?
As payment integrity leaders weigh custom vs. configurable, best practices vs. home-grown it's important to keep in mind: flexible solutions offer greater value to health plans. Whether your health plan has decided it has outgrown its manual paper-based processes or...
Data Privacy Concerns Meet Digital Progress
Data privacy and security will always be top of mind for health plans in an environment where access to data is crucial to growth. Here are some safeguards for payers. How do payers balance their need for broader access to data with their need to improve trust with...
Top 10 Reasons Health Plans Choose Pareo
It’s almost 2020, and forward-thinking health plans have a choice when it comes to total payment integrity solutions. From smaller regional plans with 100k members to large national health plans with millions of lives covered, Pareo scales to accommodate all needs....
An Aggressive Plan to Move your Claims Recovery to Prepay Status
Transitioning more payment integrity operations to internal prepay is more than just a pipe dream for health plans Transitioning prepay. It’s the holy grail for health plans — and viewed as equally unattainable. And, in the not-so-distant past, this viewpoint would...
Managing Medical Record Requests a problem? We’ve got the solution.
How to manage medical record retrieval processes with multiple clinical audit vendors to increase payment integrity savings, not provider abrasion.
Checking in: How to offer vendors a concierge experience
When we created Pareo®, from its inception we knew vendors would be an important stakeholder in the payment integrity ecosystem. As our payment integrity solution has grown (in many ways, shaped by our incredible clients), it has cemented our belief that focusing on...
Be the change agent you wish to see at your health plan
8 essential skills every change agent needs to navigate the future of healthcare Whether you’re already leading change at your organization or hoping to do so soon, most health plan employees need to be well versed in change management as the industry braces for rapid...
Communication Makes Digital Transformation Work
What happens after you choose a payment integrity solution? Learn how communication factors into successful digital transformation.Chances are, your health plan is undergoing some type of digital transformation this year, and you’re not alone. A recent survey of...
Creating a Community of Users
When you adopt Pareo®, you gain access to a large community of health plan professionals offering shared expertise. From time to time, we like to remind our readers that “you don’t have to go it alone.” That isn’t just an empty catchphrase we use to market to new...
Lack of Documentation is a $23 Billion Overpayment Problem for Medicare
Medicare overpayment is a massive problem, and lack of documentation is a significant contributor. When we see errors adding up to billions of dollars in improper payments, we pay attention. As payment integrity technology experts and also healthcare consumers we take...
The Value of Collaboration: Find Your Power
Collaborative organizations — no matter the industry — are proven to be more effective. How can you tap into this mojo? Your health plan has working relationships with members of other departments, third-party payment integrity service suppliers and providers. By...
Forget the Buzzwords. Lack of progress now doesn’t mean you’ll never catch up.
3 practical steps you can take today if your health plan is feeling left behind on advanced payment integrity technology A few weeks ago, a blog reader approached me about a recent article I wrote titled “Does Your Health Plan Even A.I.?” The reader, who also happens...
Burned out and Bored? Remind Your Employees Why Payment Integrity Matters
Address the “why” behind payment integrity and you’ll find that health plan employees no longer feel stuck. Most talented employees start out in their jobs with a great deal of optimism: meeting new people, learning new things, looking forward to making a positive...
6 Signs of Outdated Payment Integrity Processes
Working harder and harder for a 1-2% rate of return on claim spend? It’s time to update your health plan’s payment integrity processes. Today, health plans and payers are at a crossroads: margins are shrinking, members are savvier, providers are increasingly...
Status Emails Drain Health Plan Productivity
If your auditors’ workflow depends on email, there’s a more productive way forward. Confession time, health plans: how much of your auditors’ workflow depends upon email? Are they working claims based upon what they were pinged about most recently? You’re not alone....
Top 10 Ways to Maximize Your Health Plan’s Savings
Want to maximize your health plan’s savings? Of course you do. Here’s how. There’s a great deal of uncertainty in healthcare today, but one thing never changes: health plans’ desire to grow their savings. But, stuck dealing with insufficient technology or...
Provider to Health Plan: It’s not me, it’s you.
Are you playing a costly game of “Who’s got the medical record”? 90% of your health plan’s cost containment efforts are the source of provider friction. Your health plan has one directive: control medical spend. And despite tight timelines, a shortage of skilled...
Put on your cape. Your health plan may just save the healthcare system.
Health plans are in a unique position to innovate with a trickle-down effect on providers and healthcare as a whole. It’s the plot to your favorite superhero movie (and with good reason): The odds seem insurmountable, and the path unclear but there’s a hero who sees a...
Claim Spend – Is It Too High at Your Health Plan?
Examining claim spend cost at health plans, and what kind of ROI can be expected. Controlling claim spend is nearly impossible without system visibility. By that, we simply refer to the access that some technology gives health plans and payers into payment integrity...
Here’s Where Provider-Payer Relationships Need to Improve
Communication breakdowns with providers wreak havoc on a payer’s bottom line. Imagine, if you will, two scenarios in a relationship between a healthcare provider and a health plan. In one, a provider receives a letter from a health plan telling them a claim is...
Addressing the $330 Billion Elephant in the Room: Administrative Complexity
Health plans can minimize wasteful spending on administra Administrative Complexity: Complex administrative processes in healthcare organizations that are increasingly seen as unnecessary and are therefore leading to wasteful spending. Nearly 10% of the $3.3 trillion...
Prepare for CMS Audits: A Guide
Here's what to expect following new CMS payment integrity initiatives, including a guide to CMS audit protocols. The pressure is on for state-administered Medicaid programs (and the MCOs that run them). New initiatives released over the summer by CMS promise increased...
How to Maximize Vendor Partnerships with Pareo®
Payment integrity vendors are critical to the success of any health plan. As health plans realize this, they are working to create stronger partnerships. Here’s how Pareo® helps. We were talking to a health plan recently about our comprehensive payment integrity...
How to Reduce Administrative Costs for Coordination of Benefits
Make Your Processes More Efficient for COB Cost Savings It has been estimated that the administrative costs for coordinating benefits is $800 million. Let that sink in for a second – $800 million is a lot of money to spend on a process that can be improved. Other...
Stop Spinning Your Wheels
How to get your health plan out of a rut and break down big data silos. Health plans are tasked with deriving ever-more savings from their claims overpayment initiatives. But with limited people, strategy, technology or processes to accomplish their goals, are they...
Health Plan Member Satisfaction is the Price of Provider Abrasion
Is provider abrasion undoing all your best member satisfaction initiatives? After a recent medical appointment, I visited the front desk on the way out where the office manager/claims specialist let me know I had an outstanding balance from my preventive care visit...
Escape Your Spreadsheets
An expert guide for health plans seeking to digitize big data and improve productivity in payment integrity and across the enterprise. Spreadsheets are useful and can be a very powerful tool in the right hands. But are they really the best your health plan can do to...
Why Now is the Right Time for Implementation
Total payment integrity implementation can help you right now – even if your health plan is in the middle of a claims system project. You know that old saying, “The best time to plant a tree is 20 years ago. The second-best time is now.”? It’s a similar situation with...
A Clearer Path to Coordination of Benefits
COB Considerations for Medicaid MCOs Coordination of Benefits. Many Medicaid health plans will tell you that this area is a primary concern in their payment integrity program. It’s no wonder: statistics tell us that 4-8% of Medicaid MCO membership has other healthcare...
3 Considerations When Discussing Technology Change
A discussion guide for Health Plans Would you be surprised to learn that there were prominent naysayers of innovative (and now common) technologies, such as the iPhone, television and even automobiles? Each of these innovations proved revolutionary and have become a...
Fraud, Waste & Abuse is Not Total Payment Integrity
Don’t settle for “good enough” when a better solution exists. Fraud, waste and abuse (FWA) is a serious problem, one that can also be seriously misleading for healthcare payers looking to transform their revenue streams. That’s because many health plans mistake strong...