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Why health plans lose money on payment integrity programs

Health plans make large investments to automate outdated processes when it comes to claims payment integrity expecting significant savings. Unfortunately, with this approach the expected savings don’t always materialize.

However, insurers that are willing to take the step of reinventing these processes with artificial intelligence and machine learning see the rewards, with massive returns on investment and access to new areas of savings.

Which health plan would you rather be?

Coordination of benefits (COB) and fraud, waste and abuse (FWA) programs are tailor-made for reinvention through AI and machine learning due to the nature of the claims payment process. Traditional COB and FWA processes tend to prioritize larger claims, and then evaluate each claim in a relative vacuum. Even though the majority of claims are relatively small, payment integrity initiatives leave them largely alone as the cost of investigation isn’t worth the potential payout in return.

There are two main changes under the COB and FWA model. First, the customer is at the center of the process, with big data analytics used to identify the customers likely to have third-party coverage and who are most at-risk for fraudulent activity. This customer-first approach, rather than the claim-first, allows insurers to identify more claims than before.

Second, automating the claims review process with AI-powered solutions like Reliable Software's Lia drops the cost of reviewing claims low enough that it becomes more cost-effective to review a larger number of claims. While individual claims may be smaller, the sheer volume generates such significantly larger returns that insurers almost invariably determine that the investment was worthwhile.

Best practices in claims payment integrity goes beyond automation of how things have always been done. Technology can go beyond the work previously done by people to work at a speed and scale previously unimaginable thanks to AI and neural networks.

Interested in what the results could look like for your health plan’s coordination of benefits and payment integrity initiatives? Contact us to schedule a demonstration.


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