Payment Integrity leaders are stuck in reaction mode. Programs built to scale reverse that trend.

Every payment integrity leader is under pressure right now to produce savings fast. But few have the infrastructure to do so without adding more – people, vendors, or manual work – adding cost and complexity on top of what's already strained. The gap between the pressure to perform this quarter and the need to implement a system that provides greater visibility into savings opportunities at scale is where most PI leaders currently live.

The lure of quick wins

"The biggest driver is high medical spend, plain and simple," says Tate McDaniel, Chief Growth Officer at ClarisHealth. "If your target MLR is 85% and you're running at 90%, you have a real problem. Payers don't have many levers to pull, and payment integrity is one of them."

As a result, McDaniel says payment integrity leaders are engaging more vendors to create new savings while simultaneously pushing those same vendors for pricing concessions. "They're trying to hit it from both sides at once. That's a very difficult thing to pull off."

This tactic may result in immediate savings but increased administrative costs on the back end. And it does little to resolve the pressure long-term.

Sara Thomas, VP of Payer Solutions at ClarisHealth, hears more urgent language from leaders. 

"The language has shifted into 'I have an initiative to drive savings as quickly as possible,'" she says. "A lot of their urgency is driven by disruption: an acquisition, a claims system migration, some event they're responding to right now."

At the same time, she adds, "they want a smarter way to work, because the current way isn't going to keep cutting it," Thomas says. "They also have to deliver real results this year. That tension is what's creating the pressure."

AI is accelerating the pressure, not relieving it

Cost isn't the only force pushing plans toward maturity. Every PI leader is being asked about AI. But almost none of them are ready to deploy it the way leadership expects.

"AI is only as good as the data being fed into it, and right now that's a limiting factor for payment integrity," McDaniel says. 

Thomas points out simply adding AI isn’t the answer. "Every PI leader I talk to has been told to submit AI use cases to their leadership," she says. “But they need governance over AI to figure out where it adds value.” 

And the ROI story on AI isn't as clean as leadership expects. "There's an expectation that AI reduces cost. Right now, it's sometimes doing the opposite: perpetuating errors and creating more work downstream, especially on higher-dollar claims," Thomas says. 

She points to duplicate claims as an example of what gets missed without centralized visibility. "Most payers have no real way to know they're being duplicate-billed or upcoded unless they have a system built to catch that pattern systematically,” she says. “It's not a detection problem. It's a visibility problem, and no AI use case fixes that on its own." 

A new baseline 

Payment integrity has been through pressure cycles before. Early on, payers outsourced most of their cost-containment efforts. Then amid administrative cost pressures, payers looked to cut costs by proving they could insource audits. Once savings get to a steady state, the pressure doesn’t stop. A stretch of benchmarking and proving repeatable value ensues. Each cycle asks payers to do more with the same or less.

What's different now, according to Thomas, is that the baseline expectation has shifted. It’s a tailwind toward program scalability, whether payers are ready for it or not.

"Some are very aware they're stuck in a reactive posture, and they're building the business case to get out of it," she says. "They’ve realized some solutions they’ve used for a decade aren’t actually giving them a better experience or solving the root problem. They have some sense now of the level of service they should be getting, even if they can't fully articulate what's missing."

What's actually keeping leaders reactive

If the ambition to get proactive is there, what's stopping it?

Thomas points to organizational friction. "The biggest thing holding leaders back isn't vision. It's the bureaucracy of the health plan," she says. 

She's watched leaders arrive with a clear mandate, only to get blocked by an IT department confident it can build the same capability internally, or a prolonged budget cycle, or a procurement process that doesn’t fit their program goals.

McDaniel sees the same disconnect from a different angle: leaders who can sense something is wrong but can't fully quantify it. 

"If you ask them, they’ll point to budget, ownership, and access to resources. Those aren't illegitimate answers," he says. "But they really lack centralized, actionable insights, so most of them don't actually know how their program is performing. If they had that cohesive picture, they probably wouldn't struggle to get the budget or resources, because they'd have the value story to go get it." 

Thomas has seen how large that blind spot can get, even at plans that look sophisticated on paper. 

"We've seen outside hires come into a very large, centralized payer and find a $50 million gap in something pretty basic," she says. "Program maturity isn't really about size. Sometimes, the larger the plan the bigger the blind spot." 

Other leaders may be aware of the source of the problems but are unable to address it.  

"There's a large payer we're working with that already knows exactly where they're leaving money on the table. They want to stack more vendors in a deliberate pass order.” says McDaniel. “Their problem isn't strategy. It's that they don't have the infrastructure to manage that complexity."

The takeaway

Cost pressure isn't going away, and neither is the next disruption after it, whatever form it takes. The plans stuck reacting to this cycle will be just as reactive to the next one, because the underlying problem isn't the current crisis. It's the inability to build a program that provides actionable insights before the crisis hits.

"The position PI leaders want to be in, and need to be in, is having enough of the right data to make good judgment calls," Thomas says. "That's what separates the plans that are reacting to whatever's happening this quarter from those that are actually running the program."