Healthcare is complex. Fragmentation, mounting costs, and constantly evolving regulations are a challenge across health plans, patients, partners, and providers. With these complexities and the volume of healthcare claims on the rise, improper claim payments show no sign of slowing down. Indeed, for 2025, the Comprehensive Error Rate Testing (CERT) program showed an improper payment rate of 6.55%.
Payment integrity is potentially one of the biggest cost management levers for health plans, but some organizations continue to struggle getting programs to a place where they can scale and grow for year-over-year value increase.
Connecting prepay and postpay
Future‑proofing payment integrity demands a fully connected ecosystem with the right technology and logic that allows organizations to leverage automation and prevention intelligently, integrate prepay with postpay for comprehensive oversight, and engage as early in the payment continuum as possible.
But there are many potential issues that thwart this ecosystem. For example:
- Fragmented data
- Incomplete analytics and technologies
- Lack of resources for policy maintenance
- Lack of human experts
- Disconnected prepay and postpay
To enable this ecosystem, technical and data gaps must be addressed to ensure meaningful analytics and interventions based on complete, accurate information. For example:
- Crucial data elements in file formats that feed prepay payment integrity solutions are often missing and must be addressed, including outpatient, inpatient, drug or other claim types; member matching data; or accurate member eligibility.
- Claim pend capabilities need to be added to prepay workflows for effective pending and retrieving of documentation when applicable, and that doesn’t exceed prompt pay guidelines.
- Postpay intervention concepts must be comprehensive, and the synchronization with different prepay intervention systems must be tight, because without both, there will either be a lack of expert intervention ideas to shift left, or limited ability to shift them
A strong connected prepay and postpay system also incorporates effective and responsible use of AI. AI should enhance capabilities by helping to better identify patterns, summarize complex medical documentation, and support claim and policy decision-making. That said, AI is a tool, not a solution. In healthcare especially, AI should not replace human expertise. Plans should look to strategically limit AI automation to enable human specialists to improve performance and outcomes. This means not replacing human clinical decision-making or judgment. Organizations can use AI to help prepare clinical content, but not to make decisions based on that content.
When a connected prepay and postpay system is applied with the right technology, data orchestration, mix of interventions, and responsible AI use, Cotiviti believes an organization can expect some 70% or more of their payment integrity program running in prepay mode, where the remaining 30% postpay is dedicated to tackling the most difficult scenarios such as retroactive data changes, sequencing and repricing, specific provider exclusions, or prior-authorization limitations.
The path forward for payment integrity
With a truly connected prepay and postpay system in place, what’s next for payment integrity? Earlier interventions in the claim payment process will be key to the future of payment integrity. These pre-adjudication or pre-emptive measures will complete the picture and substantially reduce administrative costs for both payers and providers by ultimately producing cleaner claims.
Payers should be looking to move from purely vertical and isolated touchpoints to a continuum. For example, intervention points that seek to do the following:
- Intervene at the earliest point for the most impact
- Accelerate value realization through multiple interventions delivered through a common platform
- Integrate into existing workflows and complement existing solutions
- Infuse AI into interventions and build self-correcting and learning processes
Coupling advanced analytics like machine learning and AI with robust data orchestration creates possibilities for scalable payment integrity and reduced MLR and ALR. It is critical to blend this technical innovation with expertise and experience to close gaps, strengthen provider relationships, and maintain a high level of confidence in the accuracy and defensibility of early interventions.
Ultimately, future-ready payment integrity means building a cleaner, more connected, and more transparent claim payment continuum. Plans that commit to this end-to-end approach will be better equipped to adapt, evolve, and lead as the healthcare landscape continues to change.
To learn more about scaling your payment integrity efforts, read our full eBook, Future-proofing payment integrity.