Payment Accuracy vs. Payment Integrity

Heading into the second half of 2025, payers and providers face an uncertain economic outlook. Health spending in the U.S. increased by 7.5% in 2023 to $4.9 trillion and is expected to reach $8.6 by 2033.[1] HFMA and AHIP, two of the industry’s biggest events, took place over the last several weeks and the overwhelming consensus was that this trajectory is unsustainable. At the same time, concerns about steep Medicaid cuts and other federal funding gaps are top of mind for everyone. Both payers and providers are looking for opportunities to reduce administrative and operational spend, but both sides face budget and resource constraints.    

Rethinking payment integrity

One area that payers are evaluating for operational savings is payment integrity, which is the process of ensuring a claim is paid accurately in accordance with contracts in place and ensuring spend and utilization are managed appropriately. The objective is to reimburse providers for services performed, ensure patients understand their out-of-pocket costs, and prevent fraud, waste, and abuse.

Given the importance of payment integrity activities to economic performance, it’s not surprising that payers choose to invest heavily in independent audits, medical chart collection, payment reimbursement, and other retrospective claim revaluation activities. But most acknowledge that finding and fixing problems after the fact is more expensive and labor-intensive than getting it right in the first place.  Another challenge is that post-payment evaluation and recovery is often a shared responsibility across multiple areas, including claim operations and provider engagement teams. Given organization’s siloed structures and dated technology, it becomes difficult to gain visibility into enterprise-wide activities and performance.    

But it’s not just administrative waste that has payers rethinking payment integrity initiatives. There’s also the provider abrasion factor. Providers believe the payment integrity process is designed for payers to avoid paying for services, and they are deeply frustrated by overpayment requests. In 2024, the Availity® network processed $4.6 billion in overpayment requests. Adding to this pain is the volume of manual work required to fulfill the payer requests for documentation and medical charts to evaluate these claims.

This disruption to the provider often ends up being a burden to patients, who receive bills they don’t understand for services they assumed were covered at the time of the visit. Providers and payer member support teams frequently field calls from angry and frustrated patients looking for explanations.   

Shifting left with payment accuracy

Payment accuracy focuses on ensuring a claim is correct by moving editing activities upstream in the claim lifecycle to address problems as early as possible—a concept known as “shift left.” Claims are checked for errors at multiple points once they reach the payer workstream. The industry refers to these points as pass edits: pre-adjudication (pass 1) and post-adjudication (pass 2 and 3). Claims are also checked multiple times in the provider workstream. The term “pass” is less common here, but for consistency the claim is checked at the EHR (pass minus zero), at the clearinghouse or revenue cycle management system (pass zero), and at the payer’s gateway (also pass zero).  

Editing at both pre-adjudication and pre-payment is significantly better than post-payment, but it’s not good enough. A claim that reaches a payer immediately incurs the transactional costs associated with the claim submission (X12 837), the remittance (X12 835), and any associated documentation. When claims have errors, they cannot be auto adjudicated, so claim analysts must manually research and manage provider inquiries. Additionally, once a claim reaches the payer, the claim must be processed within a certain timeframe, or the payer may incur regulatory fines. From a provider’s perspective, slow payer processing leads to costly follow-up activities for provider staff in the form of making phone calls and sending additional documentation. There is also the overall impact on the provider organization’s revenue cycle KPIs and cost-to-collect.           

Pre-submission payment accuracy is the optimal editing solution

A better alternative to editing in the payer workstream is pre-submission payment accuracy, which shifts edits before the claim reaches the payer workstream. Pre-submission edits are applied either in the provider workstream or at the payer gateway, so if the claim has errors it can be returned to the provider to be corrected and resubmitted. Because the errors never reach the payer, claim analysts are not spending time researching issues and contacting the provider and back-office revenue cycle staff are not managing denials.    

But the true value of pre-submission payment accuracy is the ability to reach providers in their workflow with actionable feedback on how to correct the claim error. Not only does this have the short-term benefit of preventing an individual claim with an error to pass through, but the provider now has information that allows them to fix their internal processes to prevent claims with this error from being created in the first place, creating a better financial experience for the patient.    

Availity Payment Accuracy

Payment Accuracy is a comprehensive rules engine that features robust content packages and intelligent, AI-enabled technology. Payment Accuracy is built into Availity’s Intelligent Gateway and leverages the dual-sided network to apply edits before submission to the payer. Errors are communicated back to the provider so they can be fixed and resubmitted, helping to provide claim accuracy throughout the entire claim lifecycle.

Benefits for everyone, realized quickly

One of the biggest benefits of Payment Accuracy is how quickly payers and providers can see results and build trust. Sharing information upfront enhances the experience for everyone involved—payers, providers, and patients.   

One of Availity’s customers, a national payer, used Payment Accuracy edits to address recurring errors with Medicaid claims in one state caused by an NPI conflict. Just four months after implementing the edits, the payer saw a 30% reduction in claim denials. The payer also attributed these edits to $500,000 in savings from reduced regulatory penalties.

Providers affected by these Medicaid denials immediately noticed the messages and took the necessary action. The claim team that implemented these Medicaid edits were surprised at the level of positive feedback they received from providers, thanking them for the chance to correct and resubmit claims rather than manage a denial that could take weeks. 

Learn More

To learn more, visit Availity’s Payment Accuracy Solution.