Integrate Payment Integrity to Improve Provider Relationships

By Gary Call, M.D.

Healthcare providers are the lifeblood of the Medicaid system, taking care of our most vulnerable populations. State payers are increasingly focused on improving partnerships with the providers in their networks, and one of the keys to improving these relationships is ensuring accurate and timely payments.

Focusing on Payment Accuracy

Healthcare coding, billing and reimbursement processes are extremely complicated, and errors are common. Finding these errors and ensuring payment accuracy requires a claims review audit process.

Traditionally, payment integrity audits have been completed long after the care has been provided and the claim has been paid. These post-payment audit processes create significant administrative costs and burdens for providers and payers alike.

That’s why many payers are now adopting pre-payment clinical claim review processes to reduce the administrative burden for their provider partners.

Easing the Burden on Providers

Executing pre-payment clinical claim reviews using tools and systems purpose-built for the task can reduce provider pushback. In fact, providers actually experience many positive benefits from these reviews, including:

  • Faster time to accurate payments, as the process is done correctly from the beginning
  • Educational opportunities for billing and claims staff, as claims submission errors are identified while the claims are still in process
  • Elimination of the need to find old and possibly archived medical records documentation
  • Ability to review the audit while those participating in the care are still familiar with the case
  • Elimination of difficult financial reconciliation of claims adjustments long after initial payment was received

Providers may initially express concern that pre-payment clinical claim reviews will delay their reimbursement. However, experience has shown that when properly implemented, a pre-payment process actually has significantly lower rates of provider complaints and appeals.

Creating Truly Integrated Payment Integrity

To meet prompt payment regulatory requirements, speed is of the essence in a successful pre-payment clinical claim review program. It is critical that data exchanges between the payer and the payment integrity vendor occur rapidly. Clean claims can then be approved for payment, while only the claims with a high probability for errors are selected for medical record review.

One way to ensure speed and accuracy of the data exchange for state government payers is to integrate pre-payment clinical review processes directly into the claims payment module of the Medicaid Management system, making it part of the claims adjudication and payment process instead of a separate activity down the line. If analytics detect a high likelihood of an error, a claim can be flagged for review immediately and payment is paused. Meanwhile, the majority of claims can proceed through the system without delay.

In addition to increasing payment accuracy, integration with the Medicaid Management system avoids the extra administrative work that comes with multiple procurements and reduces the costs and potential for mistakes that come with additional file exchanges.

Improving Processes, Increasing Efficiency

Moving clinical claims review to a pre-payment process maintains an important program integrity function while easing the administrative burden on network providers and ensuring accurate and timely payments. Going a step further, and actually integrating pre-payment clinical claim reviews directly into the claims payment process, allows the speedy processing critical to pre-payment programs while simplifying administration for state payers.

The market is moving toward comprehensive and streamlined payment integrity. Greater efficiency at the beginning of the payment process benefits both payers and providers — and, in the end, the entire Medicaid ecosystem.

To learn more about Gainwell Technologies’ payer and provider-friendly pre-payment clinical claim reviews, visit

The editorial staff had no role in this post's creation.