Payment Accuracy: Shifting from Recovery to Prevention 

In a recent episode of The Claim Game podcast, Availity’s Anne Neal, Vice President of Product at Availity, joins hosts Jeremy Zug and Catherine Zug to discuss a critical shift taking place in healthcare–from payment integrity to payment accuracy. Their conversation explored how health plans can move beyond fixing payment errors after the fact and to focusing on preventing them before claims are even submitted.  

Key Conversation Insights 

• Prevention offers greater value than post-payment recovery. 

• Cleaner claims reduce denials, administrative costs, and provider friction. 

• AI and real-time insights are helping health plans improve payment accuracy earlier in the claims lifecycle. 

Health plans face growing pressure to improve efficiency, lower costs, and strengthen provider relationships. While traditional payment integrity programs have focused on identifying and recovering inaccurate payments, there is increasing recognition that preventing errors before they occur delivers far greater value across the healthcare ecosystem. 

Podcast Episode Key Takeaways  

What’s the Cost of Getting Claims Wrong? 

Payment inaccuracies affect more than financial performance. Errors often trigger claim rework, appeals, payment delays, and friction in payer-provider relationships. 

These hidden costs impact everyone in the claims process. Providers spend valuable time correcting and resubmitting claims. Health plans dedicate resources to managing avoidable exceptions and investigations. Patients may also experience care delays and frustration over surprise bills. 

While recoveries and overpayments can be measured, the broader operational burden created by preventable errors is often harder to quantify. Yet these inefficiencies consume significant time, resources, and attention across organizations. 

As a result, says Anne, healthcare leaders should focus on improving claim quality at the source rather than correcting problems after payment has already occurred. 

Prevention is the Foundation of Payment Accuracy 

Historically, payment integrity programs have relied on a retrospective approach. Claims are processed and paid, then reviewed later to identify inaccuracies. 

Today, advances in data connectivity, automation, and AI are making a more proactive model possible. Health plans can now move payment accuracy efforts earlier in the claims lifecycle, an approach Anne calls “shifting left.” 

Instead of identifying issues months after payment, plans can provide guidance before or during claim submission. For example, if payer requirements call for a specific modifier or supporting documentation, communicating that information at the point of claim creation can help providers improve claim submission accuracy. 

The benefits are significant. Providers may receive reimbursement faster, while health plans may reduce denials, rework, and administrative costs. Rather than spending resources correcting mistakes, both parties can focus on delivering value. 

Prevention transforms payment accuracy from a recovery exercise into an operational strategy that improves outcomes across the entire workflow. 

Aligning Payers and Providers Around a Common Goal 

Payers and providers often approach reimbursement challenges from different perspectives, but they share a common objective: reducing unnecessary administrative burden. 

Denials, appeals, and corrections create work for both sides. Providers devote staff and resources to resolving claim issues, while health plans must review appeals, answer inquiries, and manage exceptions. As Anne says, neither party benefits when claims require multiple touchpoints before payment is finalized. 

A prevention-first approach creates better alignment. When claims are submitted accurately from the start, providers experience fewer administrative hurdles and more predictable reimbursement. Health plans benefit from improved efficiency and lower operating costs. 

This shared value highlights why payment accuracy should be viewed as a collaborative effort rather than a payer-only initiative. Success depends on making it easier for all participants to get claims right the first time. 

The Importance of Transparency 

For many providers, payment rules can seem unclear. Decisions may seem to lack context. Transparency helps change that dynamic. 

When providers have access to clear requirements and actionable guidance before submitting claims, they can address issues proactively instead of reacting to denials after the fact. Delivering that information within existing workflows helps reduce confusion and supports more consistent claim submission practices. 

The result is not only improved efficiency but also stronger trust between payers and providers. Organizations that prioritize transparency can reduce friction, improve collaboration, and create a more positive administrative experience across the healthcare ecosystem. 

The Value of Network-Scale Intelligence 

Healthcare data has traditionally been fragmented across organizations and systems, making it difficult to identify larger patterns and trends. 

Individual health plans can uncover issues within their own claims environments, but broader visibility creates opportunities for deeper insights. Analyzing activity across a connected network can reveal recurring billing challenges, emerging trends, and opportunities to improve claim quality before errors occur. 

Network-scale intelligence enables organizations to move beyond isolated problem-solving and take a more proactive approach to payment accuracy. By understanding what is happening across the broader ecosystem, health plans can deliver more effective guidance and implement strategies that help prevent issues at scale. 

Anne emphasizes that the goal is not to replace traditional payment integrity efforts. It is to give them the space to do what they do best: work complex claims, prevent fraud, waste, and abuse, and ensure the appropriate application of medical policy. 

AI Is Accelerating the Shift 

Artificial intelligence is playing an increasingly important role in helping health plans improve payment accuracy. Rather than replacing human expertise, AI can help organizations analyze larger volumes of data, identify patterns earlier, and surface insights directly within existing workflows. 

Potential benefits include: 

• Earlier issue detection 

• Fewer preventable denials 

• Higher first-pass claim acceptance rates 

• More efficient administrative processes 

• Better allocation of staff resources 

As adoption grows, successful AI programs will depend on strong governance, transparency, and human oversight. When implemented responsibly, AI can help health plans scale preventative strategies while maintaining consistency and accountability. 

Looking Ahead 

Payment integrity will always play an important role in protecting healthcare resources and ensuring appropriate reimbursement. But the greatest opportunity lies in preventing avoidable errors before they occur. 

By emphasizing prevention, transparency, network intelligence, and AI-powered insights, health plans can reduce administrative burden, strengthen provider relationships, and create more efficient payment workflows. 

The future of payment accuracy is not simply recovering errors after payment. It is creating an environment that helps improve claim accuracy from the start, reducing friction across the healthcare ecosystem and delivering a better experience for payers, providers, and patients alike. 

Learn more about Availity’s payment accuracy solutions for health plans.