Post-Payment Accuracy & Integrity Solutions (Payer)
Vendor software solutions used by health plans to help ensure accurate payment/reimbursement to providers. Specifically limited to post-pay functions (i.e., processes that identify or recover losses after payment is made).
Report Abstract
Key Findings:
- Vendors That Provide Pre-Payment & Post-Payment Solutions: Cotiviti and Optum Provide Broadest Solutions; Outcomes and Value for Customers Vary, Particularly with Optum
- Vendors That Provide Pre-Payment Solutions: Zelis Healthcare Customers Are Most Satisfied; Lyric & HealthEdge Customers See Outcomes but Want More Proactive Engagement & Functionality
- Vendors That Provide Post-Payment Solutions: Conduent & EXL Used for Payment Recovery & Analytics Respectively; Customers of Both Report Receiving Value
Market Introduction
Payment accuracy and integrity involves several steps, and KLAS research finds that payer organizations normally use multiple vendors for different steps (i.e., pre-payment vs. post-payment) and for different capabilities (i.e., claims editing, payment recovery). Some vendors say they provide broad capabilities across most or all areas, while others focus on providing offerings for certain steps in the payment accuracy and integrity cycle. These solutions are typically used across all different lines of business. Historically, payers and vendors have focused on correcting under- or overpayments when they occur; more recently, the market has emphasized accuracy before payments are made.
What KLAS Does
KLAS is a healthcare-focused research firm whose data helps provider, payer, and employer organizations make informed software and services decisions. Our reports exist because customers (including health plans) speak with KLAS and share invaluable insights; all performance data is based on feedback from these interviewed customers.
Key Definitions
Note: This is not a comprehensive list of payment accuracy and integrity processes but rather a list of the major components.
Pre-payment: Processes that ensure accuracy before payment is made
- Claims pricing: Calculates accurate pricing for which payer is liable based on reimbursement methods and related rules
- Provider education: Instruction for/engagement with providers to help facilitate accurate coding and claims submission
- Claims editing: Reviews and tests rules to ensure consistency and accuracy of items listed on a medical bill
Post-payment: Processes that identify or recover losses after payment is made
- Coordination of benefits (COB): Determines members’ primary coverage/plan; mostly done post-payment (some vendors may offer ways to identify COB-related issues pre-payment)
- Data mining: Identifies and recovers billing or payment errors through data analytics
- Subrogation: Reimbursement for payers by the party at fault who caused damage to the member
- Credit balancing: Identifies overpayment to provider organizations and manages credit balances
- Fraud, waste, and abuse (FWA): Detects, corrects, and prevents fraud, waste, and abuse (which account for a large portion of costs for payers)
Key Industry Trends
- Payers are looking for increased accuracy and savings by using multiple vendors for different lines of business/types of bills as well as for different functionalities/processes.
- Vendor business models are evolving to include software/SaaS (in addition to services and contingency models).
- Payers are looking to focus more on pre-payment solutions to ensure accuracy before payment, marking a shift away from the traditional pay-and-chase model. This prospective payment model is expected to reduce administrative costs for both payer and provider organizations.
- Due to friction in payer-provider relationships, many payers are recognizing the need to improve collaboration with provider organizations. Friction in these relationships can not only add more administrative costs for both parties but also be detrimental to the patient experience. As payers work to be more proactive and more accurate in payment efforts, they anticipate that provider relationships will naturally improve and desirable networks will be better sustained.
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Performance Data
Overall Score by Product
Overall Score by Question Topic
Provider Facility Size by Product
Provider Facility Type by Product
Reducing Filters
Unlike sizing filters, reducing filters DO NOT recalculate scores based on the evaluations that meet these requirements. They narrow the list of solutions to show the vendors and solutions that can meet a specific need.
This data is based on interviews with a sample of the firms' recent clients. As a result, it is not necessarily comprehensive of all work a firm may do in this segment.
We require a minimum of 2 confirmations of a service performed in the last 3 years for a solution to qualify.