The self-insurance industry is witnessing a growing demand for effective payment integrity measures, driven by rising healthcare costs and the need to address inappropriate medical spending. In particular, third-party administrators (TPAs) and other benefit administrators are under increasing pressure to implement robust payment integrity programs to maintain their competitive edge and satisfy self-funded employers. Payment integrity ensures that healthcare claims are paid accurately and appropriately, and can be deployed either before claims are paid (prepay) or after claims are paid (postpay).
Prepay solutions analyze claims before they are processed to prevent inappropriate payments. Automated claim editing systems are the cornerstone of prepay integrity, ensuring compliance with internal policies and national guidelines. These systems can be supplemented by extra layers of prepay review to handle complex coding scenarios. Meanwhile, postpay solutions focus on recovering overpayments after claims have been paid. Although necessary, pursuing postpay recovery is often less efficient and can strain relationships with healthcare providers. Therefore, prepay solutions are vital for preventing payment errors and maintaining provider satisfaction.
TPAs that do not offer prepay integrity services risk losing their competitive advantage. According to Cotiviti data, 74% of Cotiviti health plan clients with administrative service only (ASO) lines of business are already integrating prepay final filter editing with self-insured employer groups. Implementing these solutions can help TPAs improve client retention, reduce employee out-of-pocket costs for their clients, and help meet their fiduciary responsibilities as claim processors.
Join me and my colleague Chris Ellsworth for a webinar Thursday, November 14 at 1 pm ET as we break down:
- Best practices in prepay integrity program design
- Strategies for TPAs and employers to work together
- Important technical and clinical components to consider
Don’t miss this opportunity to enhance your competitive standing and meet your clients' needs by implementing effective payment integrity solutions.
For another deep dive, read our newly published white paper breaking down the fundamentals of payment integrity for TPAs—and offering five crucial criteria for evaluating potential payment integrity partners.
