Why Payment Accuracy Is the Evolution of Payment Integrity

Health plans have made significant investments in payment integrity programs to ensure accurate reimbursement and address complex claims. However, as denials and administrative complexity have grown, many payment integrity teams have been pulled away from their highest-value work into resolving preventable issues. The result is that handling denials, appeals, pends, audits, and recovery efforts downstream has become routine, even when many of the underlying errors could have been addressed before a claim was ever submitted. Payment accuracy is a better model.

Blog Key Takeaways

• A significant amount of rework on claims errors downstream could be prevented upstream with a new model: payment accuracy 

• Payment accuracy does not replace payment integrity; the two work in tandem 

• A payment accuracy model shifts common clinical, coding, and policy checks to the point of claim submission 

• A mature payment accuracy model is workflow native, combines clinical and administrative intelligence, scales across networks, and aligns siloed team 

The problem isn’t that payment integrity isn’t working. The problem is timing. According to the 2026 Availity Abrasion Index, approximately 10% of claims are denied, but more than 70% of those denials are ultimately overturned. That’s evidence that a significant amount of administrative effort is spent resolving issues that might have been prevented in the first place.  

As healthcare costs continue to rise and operational complexity grows, this misplaced effort is becoming untenable. The industry needs a new model: payment accuracy.

Payment accuracy is an operating model that shifts the focus of claims operations upstream, bringing payer guidance closer to the point of claim submission.  

What Is Payment Accuracy? 

Payment accuracy does not replace payment integrity. Instead, it complements and strengthens payment integrity by preventing avoidable errors before claims enter payer systems.  

Traditional payment integrity programs excel at reviewing claims after submission. They identify issues related to reimbursement, compliance, and utilization management. However, many of today’s denials stem from administrative issues such as eligibility verification, documentation gaps, prior authorization requirements, or coding inconsistencies—issues that can often be addressed earlier in the workflow. 

A payment accuracy model shifts common clinical, coding, and policy checks to the point of claim submission. That enables providers to address issues before a claim is denied or delayed. The result is a less abrasive process for payers, providers, and members alike.  

Why does the Current Model Create Friction? 

Healthcare has largely normalized downstream rework. Organizations budget for denials management, staff appeals teams, invest in recovery efforts, and implement processes to address claims after problems arise. They have normalized downstream rework. 

But downstream rework creates: 

• Increased administrative costs through vendor stacking 

• Higher volumes of appeals and pends 

• Fragmented, siloed workflows 

• Provider abrasion and dissatisfaction 

• Member confusion and unexpected bills 

• Additional strain on payment integrity teams  

The eBook, Why Payment Accuracy is the Next Operating Model for Payment Integrity, argues that many of these challenges share a common root cause: payer requirements and provider workflows are often disconnected until after a claim enters the system.  

What Are the Five Characteristics of a Mature Payment Accuracy Model? 

According to the eBook, successful payment accuracy programs share five characteristics:  

1. They operate upstream, before avoidable errors become denials or rework. 

2. They are workflow-native, delivering guidance where providers already work. 

3. They combine clinical and administrative intelligence to support better decision-making. 

4. They scale across networks, not just individual providers or health systems. 

5. They align cross-functional teams, including payment integrity, claims operations, provider relations, and medical policy.  

Rather than adding another bolt-on product, payment accuracy creates a framework for collaboration and transparency between payers and providers. 

What Does Success Look Like Beyond Improved Denial Rates? 

Reducing denials is important, but it’s only part of the story. 

Organizations adopting a payment accuracy approach should evaluate broader outcomes, including: 

• Reduced rework and appeals 

• Lower administrative costs 

• Fewer manual touches 

• Better provider experiences 

• Improved member satisfaction 

• Greater focus on complex payment integrity work 

• Reduced IT and vendor expenses  

The shift isn’t simply about processing claims faster. It’s about preventing unnecessary work from entering the system in the first place. 

Why Does Payment Accuracy Matter Now? 

U.S. healthcare spending reached approximately $4.9 trillion in 2023 and continues to grow. At the same time, the industry spends more than $25 billion annually on claims adjudication, including billions tied to rework for claims that are ultimately paid anyway.  

As healthcare organizations face mounting pressure to improve efficiency, reduce costs, and deliver better experiences, the traditional “pay-and-chase” model becomes increasingly costly to sustain.  

The Future of Payment Operations 

The future of payment operations will likely be defined less by how effectively organizations recover errors and more by how successfully they prevent them.  

Payment integrity will remain essential for addressing complex claims, detecting fraud, waste, and abuse, and supporting appropriate reimbursement. But leading organizations will reap more value from shifting common administrative and policy-related issues upstream.  

By embedding guidance directly into provider workflows and creating greater alignment between payers and providers, health plans can improve efficiency while reducing friction across the ecosystem.  

In Why Payment Accuracy Is the Next Operating Model for Payment Integrity, you’ll learn: 

• Why healthcare has normalized rework—and why that’s a problem 

• How payment accuracy complements payment integrity 

• The framework for building an upstream operating model 

• The metrics that matter beyond denials 

• The role AI and network-scale connectivity will play in the future of claims management 

• How organizations can reduce administrative waste while improving provider and member experiences  

Download the eBook to explore the payment accuracy model and discover how healthcare organizations can move from correcting errors after the fact to preventing them at the source.