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Factors leading to payment integrity challenges

While the basic challenges to health insurance payment integrity remain largely the same – ensuring responsibility for the claim, the eligibility of the consumer, the coverage under the contract, the validity of the claim and the lack of fraud, waste and abuse – the range of factors that bear on those challenges has expanded over time. Fortunately, so have the capabilities of insurers to deal with those challenges through modern coordination of benefits (COB) functions. Some of today’s challenges to payment integrity are:

  • Providers seeking reimbursement. Healthcare providers are leveraging data and analytics to more aggressively pursue reimbursement, sometimes even before insurers have been alerted by the consumer.
  • Evolving Internet crime and fraud. Digital crime is creating new fraud, waste and abuse (FWA) challenges for insurers. Identity theft is all too common and can create not only invalid claims that can be difficult to identify until too late, but significant customer service challenges for insurers whose customers have been victimized.
  • Human limitations and errors. Customers often don’t know what supplemental coverages they might have in a particular circumstance, neglect to inform providers or insurers of changes to insurance status or otherwise don’t provide complete or truthful information. Providers make administrative mistakes, whether in claim coding or otherwise and perform wasteful or unnecessary tests or procedures.

None of these challenges are new, although the mechanism through which these factors contribute to COB challenges can often evolve as automation takes over and the speed of interactions increases. The good news for insurers is that the degree to which these factors create or exacerbate payment integrity challenges is far outweighed by the power of AI-powered COB systems to apply the power of multiple layers of neural networks to identifying and untangling these challenges through machine learning.

Artificial intelligence may not end the human error and misdeeds that factor into so many payment integrity challenges, but it does provide a powerful and constantly-learning ally in identifying where those challenges have been created and what can be done to address them. In fact, AI-driven COB empowers payment integrity more than ever before, opening new levels of lower-cost claims to evaluation than ever before thanks to its automated efficiency where human review would not be cost effective.

If you’re interested in what you can do to address both new and historic factors challenging your payment integrity, contact us to find out more.


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