Availity’s New Resource Lays Out How to Shift from Payment Integrity to Upstream Payment Accuracy

Payment integrity is intended to ensure that claims are legitimate, medically necessary, and financially appropriate. However, the current model is implemented through lookbacks or post-payment recovery, which costs both time and resources. Collectively, an estimated $25 billion is spent annually on claims adjudication, with $18 billion tied to reworked claims that ultimately get paid.

Payment accuracy moves the claims review process upstream, where administrative, clinical, and payer-policy guidance is applied before a claim is ever created. This model allows providers to identify and resolve avoidable issues in real time, reducing the volume of downstream rework and allowing payment integrity teams to focus on the complex scenarios where their expertise delivers the greatest value. 

A mature payment accuracy model shifts the detection of common coding, clinical, and policy errors to before the point of submission. That allows payers to return clear, actionable edits to providers before the claim crosses the payer’s threshold. 

Payment accuracy should embed payer-managed rules, clinical logic, and policy guidance directly into the provider’s claim submission workflow—before the claim reaches the payer’s systems. This model can identify eligibility issues, coding mismatches, contract misalignment, and documentation gaps in real time, enabling corrections before payment occurs. 

Payment integrity will continue to play a critical role in ensuring that claims are legitimate, medically necessary, and financially appropriate. However, it’s too often used to address preventable issues only after claims have already entered the payer system. That adds administrative burden and higher costs for everyone. 

Payment accuracy focuses on prevention by addressing issues before claims are submitted, reducing costs and complexity. Payment accuracy shifts correction to the point where it is most effective—before submission—reducing avoidable rework, lowering administrative costs, and minimizing friction across the ecosystem. In doing so, it allows payment integrity to operate at its highest value: managing complexity, not cleaning up preventable errors. It also gives providers clearer guidance before submitting a claim, so they can focus more on patient care and less on administrative tasks. 

In an ideal state, payment integrity teams focus on high-value activities: analyzing complex medical claims, identifying and addressing fraud, waste, and abuse, and partnering with medical policy teams to define and enforce appropriate payment rules.  

AI can help improve claims and the submission process by enabling the early identification of claim errors, allowing providers to prevent avoidable denials and reduce administrative burden at scale. Specifically, it will help organizations: 

• Predict recurring sources of error earlier in the lifecycle 

• Deliver real-time, actionable guidance to providers 

• Identify patterns in errors and help teams prioritize fixes

Availity combines network scale, payer connectivity, claims intelligence, and predictive analytics to enable real-time exchange for processes including eligibility, authorizations, claims, clinical information, and more. Through this network, payers and providers have tools to surface valuable insights that can reduce abrasion between parties. 

Download the eBook:  “Why Payment Accuracy Is the Next Operating Model for Payment Integrity.”