Payment Integrity Needs Payment Accuracy

It’s time to rethink payment integrity. 

For decades, payment integrity has been a critical function within payer organizations, created to address high-value, complex claims, combat fraud, waste, and abuse, and apply medical policy. It was designed for a healthcare system where volumes were lower, variation was manageable, and intervention after the fact made sense. 

But that system no longer exists. 

Key Takeaways

• Payment integrity teams spend too much time on low-value claims work.
• A payment accuracy model focuses on preventing errors before they enter the payer ecosystem.
• Payment accuracy works hand-in-hand with payment integrity.
• Availity’s payment accuracy solutions can help payers avoid rework.

Why is payment integrity alone unsustainable?

Fixing claims after submission is no longer merely inefficient for payers. It has become unsustainable for providers, too, who must spend more time on administrative tasks rather than on patient care. Payer-provider friction over denials and other preventable errors reflects the administrative waste on both sides. 

Today, payment integrity teams are increasingly tasked with correcting high volumes of low-value errors, many of which could have been prevented upstream. The result is a growing mismatch between what payment integrity was built to do and what the current healthcare system demands of it. 

To remain competitive, payers must shift their approach from addressing errors downstream to preventing them. They must adopt a payment accuracy model.

The High Cost of the Current Payment Integrity Model 

At its core, a downstream recovery-based model introduces friction at every stage of the claims lifecycle. 

When errors are caught after submission, claims enter a cycle of denials, appeals, or other after-the-fact fixes. Each step compounds administrative effort and raises costs. What begins as a simple discrepancy quickly cascades into a multi-touch workflow involving multiple teams, systems, and often external vendors. 

Over time, organizations have compensated by stacking vendors to audit, review, and recover payments. They have instituted complex, sometimes redundant, workflows to track and resolve exceptions. They have expended resources on complex IT integrations. But these layers don’t address exceptions. They make them harder to manage. 

What Is Payment Accuracy? 

Payment accuracy represents a fundamental shift in where and how claims errors are addressed. 

Instead of correcting claims after they enter payer ecosystems, payment accuracy focuses on validating claims before submission. It creates more transparency for providers around payer rules at the point of submission, where errors can originate. 

The principle is simple: you can achieve accuracy before a claim is processed, not after it fails. 

This is not just an operational improvement or a bolt-on product. It is an organizational shift. 

What Does Payment Accuracy Look Like in Practice? 

In a payment accuracy model, payer requirements are no longer opaque or reactive. They are more transparent at the point where claims are created and submitted. 

This enables providers to: 

• Correct eligibility issues in real time 

• Address missing documentation before submission 

• Align with payer policy requirements up front 

Many of today’s denial categories highlight this opportunity. For example, a significant portion of denied claims are ultimately overturned, indicating that the issue was not about medical necessity, but a preventable administrative error. Many of these events are predictable. We can intervene before they occur. 

At scale, we can support this shift through network-based approaches, where payer requirements are standardized and distributed across provider ecosystems. Instead of managing thousands of variations reactively, payers can define rules once and enable consistent adherence upstream. 

Payment Integrity Still Matters. But Why Must It Evolve?

This shift does not diminish the importance of payment integrity. Payment integrity remains essential for: 

• Complex claims requiring nuanced review 

• Detection of fraud, waste, and abuse 

• Enforcement of clinical and medical policy 

By preventing common errors upstream, organizations can free payment integrity teams to focus on higher-value work. The function can operate as it was originally intended. 

Why Is Payment Accuracy More Possible Than Ever?  

Today, several enabling factors have converged: 

• Mature network connectivity between payers and providers 

• Real-time data exchange capabilities 

• Advances in AI that enable earlier pattern recognition and validation 

Also, the industry has become increasingly aware of where friction occurs in the claims process. There are powerful tools to intervene.  

What Comes Next? 

Payment integrity will remain a critical part of the healthcare system. But it cannot remain the foundation of a payer’s payment strategy. 

Payers that lead will be those that move intervention earlier, shifting the focus to where claims are created, not corrected. The goal is not simply to recover more dollars. It is to prevent unnecessary losses in the first place. 

Learn how a network-enabled approach to payment accuracy can help you prevent avoidable errors, reduce administrative costs, and scale with confidence.

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About the Author

Anne Neal, Vice President of Product and Payment Accuracy at Availity, brings over 20 years of extensive experience in product development within the healthcare industry. With a focus on leading product portfolios and driving innovation in both payer and provider spaces, Anne has established herself as a visionary leader.