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How one health plan realized more than $1 million in administrative savings with upfront claims editing


A regional health plan with over 5 million members wanted to improve its clean claim rate without increasing the burden on its provider network.


Reworking inaccurate claims can involve hours of internal research, as well as a lot of back-and-forth communication with providers—all of which drives up administrative costs. A regional health plan wanted to solve for this by stopping bad claims before they reach adjudication.

“We needed a solution that would reduce the costs associated with claims rework without increasing provider abrasion.”

Senior director of provider connectivity solutions/EDI operations


Payment Accuracy is a robust two-sided editing platform that resides within Availity’s Intelligent Gateway and prevents claims with errors from reaching health plans.

The health plan leveraged editing content available in Payment Accuracy’s Clinical and Analytics module for a pilot program. It deployed 11 edits based on ICD-10 coding rules, including:

  • Anesthesia performed by a non-anesthesia provider
  • Procedure codes not typical for a patient’s age
  • Modifier that is not typical for a procedure code

Over the next three years, the program would expand to include 25 edits.


First year of pilot program

11 edits = 111k inaccurate claims stopped

Third year of pilot program

25 edits = 650k inaccurate claims stopped

The health plan estimates approximately

650k inaccurate claims stopped = $1.6M in administrative savings

Calculation based on 25% of claims requiring rework at an estimated cost of $4/claim.

“Everyone benefits from cleaner data. For us, it reduces rework. For providers, it improves analytics and revenue cycle times, helping them get paid faster. With the right edits, all parties can win.”

The plan’s senior director


While the plan implemented just a fraction of edits available, the results from this small sample showed the potential savings available by deploying additional edits. It also showed the power of edits to drive cleaner claims. Available within Availity’s Intelligent Gateway, Payment Accuracy helps prevent inaccurate claims, reducing downstream administrative costs.

Find out how payment accuracy can reduce claim re-work without burdening the provider.