Payment Accuracy & Integrity Solutions 2023
Financial Outcomes Top of Mind

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.

Vendors That Provide Pre-Payment & Post-Payment Solutions

Cotiviti and Optum Provide Broadest Solutions; Outcomes and Value for Customers Vary, Particularly with Optum

Payers of all sizes use Cotiviti and Optum, who both provide broad offerings that cover pre-payment and post-payment processes. Due to these broad functionalities, Cotiviti and Optum tend to operate in a more complex environment, which requires having expertise in all areas and doing multiple implementations, and that can consequently lead to challenges. Most Cotiviti customers use the system for pre-payment claims editing during the second pass and view the vendor as the market-share leader in second-pass editing. Additionally, Cotiviti is the only measured vendor with respondents who report using the system during the third pass (arguably the most difficult stage to identify additional inaccuracies/savings). Customer outcomes vary—some respondents see benefits such as captured billing errors, few false positives/negatives, improved finances, and good reports; others are less satisfied with the solution’s ability to facilitate accurate payments. A few respondents feel they haven’t received the desired ROI due to high costs and complicated reports.

Optum—who offers the broadest solution among measured vendors—receives the lowest customer ratings; respondents report that technical glitches (e.g., lack of integration within the product, false positives) prevent them from fully using the product. Multiple customers feel Optum isn’t a partner, isn’t invested in customer success, and doesn’t understand customer needs. Optum’s ownership by UnitedHealth Group (the largest US health plan company) and quick growth through acquisitions are also concerns for some customers. Despite these challenges, most respondents feel the solution is easy to use, citing outcomes like better edits/reviews, more savings, and more efficiency.

Vendors That Provide Pre-Payment Solutions

Zelis Healthcare Customers Are Most Satisfied; Lyric & HealthEdge Customers See Outcomes but Want More Proactive Engagement & Functionality

Zelis Healthcare offers software for claims editing and hospital bill reviews (first pass and second pass), and some customers report using the solution for provider education. Their customer base includes mostly small/midsize organizations but also some large organizations. Interviewed payer and TPA customers give Zelis the highest overall performance score in this market segment as well as across all KLAS-measured payer markets. Customers highlight the affordable, easy-to-use interface and the integration with core claims systems; they also appreciate outcomes such as cost savings, fewer billing errors, and explanations of edits. Reported improvement opportunities include better phone support and provider communication to support payer-provider relationships. Lyric ClaimsXten (formerly part of Change Healthcare) specializes in first-pass claims editing; interviewed customers report sizable savings and yearly optimization studies and note the solution can handle large claims volumes. The vendor is seen as having good customer relationships and expertise in CMS regulations, and they meet customer needs through collaboration. Respondents also mention that the Change Healthcare transition was smooth thanks to good communication. Some report challenges with inconsistent execution during upgrades and implementations, a difficult interface, and insufficient vendor expertise/guidance. HealthEdge Source (formerly Burgess) is known for first-pass claims editing and pricing, particularly for Medicare/Medicaid programs. Customers appreciate the high accuracy (which they credit to biweekly updates with CMS pricing information), and they note the vendor is willing to listen to them and provides quality support when issues occur. Respondents anticipate more functionality developments (e.g., better integration) in the future, and a few want HealthEdge to more proactively reach out about development/implementation timelines.

Vendors That Provide Post-Payment Solutions

Conduent & EXL Used for Payment Recovery & Analytics Respectively; Customers of Both Report Receiving Value

Vendor Bottom Lines

Vendors ordered alphabetically

Fully Rated Vendors

Conduent

“I would tell others that Conduent is very easy to work with. They like to bring things to our attention, especially when it comes to collections of outstanding money. The vendor lets us know that they want to try to collect as much as they can. If something is holding up a collection, Conduent tries to provide a solution to the problem without asking for extra money. They are good in that way. In terms of collecting money and meeting goals, the vendor does their job.” —Manager

“Conduent doesn’t train us very much on functionality or best practices per se. They are trying to find the recovery and basically make sure we are not missing any money, but there is not as much talk about what we can do better in order to improve our internal processes.” —Manager

Cotiviti

“We selected Cotiviti because they were pretty much the only player in town for second-pass claims editing. The vendor was and still is considered to be the best in class. We looked at a couple of other vendors who offered some tools for claims editing, but the capabilities of those vendors’ products did not compare to the capabilities in Cotiviti’s system at the time.” —VP

“The product works as promoted, and the vendor was not shy about telling us the appeal rates. The vendor was transparent about certain things but not about their editing, which has been a ding on Cotiviti for years. We don’t know 100% what they are doing with each edit. We only have a general description, and that makes it very hard to be defensible to providers when they call about the edit. It feels like we are just shooting in the dark.” —Director

EXL

“Our experience with EXL has been great. The vendor has been really good with communication, and they are always quick to respond. If I send the vendor an email, they will respond to me within the hour. The vendor’s subject matter experts for various projects are very knowledgeable and quick to respond to our questions. The vendor seems to have their processes down to a science. That is very helpful for audits.” —Manager

“There are a lot of reports that go back and forth. There are errors in the reports, so the reports require a lot of babysitting, and that is very time consuming.” —Manager

HealthEdge

“What sets HealthEdge apart from other vendors is the capability to look up the Medicare rates in the system. I love that capability. If we have, for example, a provider that says that we didn’t price a claim correctly, we love the way that the audit tool can go in and look at the claim. It explains every single line, what edits fired, why they fired, what payment was calculated, why it was calculated, and whether there was a modifier driving something. There is a lot of great detail behind how the claim was priced. All of that information is at our fingertips in that tool, and before we moved to the HealthEdge product, other tools did not have those capabilities.” —Director

“Getting visibility into the vendor’s timelines and performance has been hard. There isn’t transparency to evaluate their patterns. We have to wait for the functionality that we are expecting.” —Director

Lyric (ClaimsXten)

“The ticket price is significant, but the reputation of the product in the industry is top of the line, and it is essential for a carrier or a third-party administrator to have code editing to ensure the appropriate adjudication of claims. The solution has been an integral piece of our value story in showing the benefits, and its value is definitely measurable in terms of impact on clients, books of business, products, and solutions. It is a key part of our value story. We are satisfied.” —COO

“From a payment-integrity perspective, we would like Lyric to look for policy opportunities or solutions. They do that to some extent, but we have to ask whether they are actually scanning the market to see what other payers are doing and offering. Increasing the frequency of those scans would be great. I would also like to see more brainstorming ideation where we bounce ideas off of each other to search for or identify potential opportunities. I want Lyric to ask what they can do to improve. One opportunity could be exploring exclusions that we currently have because we sometimes get things wrong.” —Director

Optum

“As we see things that another vendor is not covering, we can utilize Optum Payment Integrity Solutions to pick up some additional savings. COVID-19 created a lot of costs, and we are definitely at the point of looking to find every nickel, dime, and quarter that we can in terms of savings. Optum’s product is helping us to create efficiencies.” —Manager

“Optum is pretty rigid, not only through contracting but through the whole product cycle. They are pretty rigid on their upgrades, releases, and so forth. When we think of what we are paying with rebundling and whatnot, the cost has gone way up, but we do not know that the value has kept up with it.” —CIO

Zelis Healthcare

“One thing that is important to mention is that Zelis Healthcare seems to be interested in and understand our operations. I can compare them to another very important vendor of ours who always wants to learn more about us so they can sell us more products. Zelis Healthcare is willing to engage with us and understand our business model, whether that means they can sell us more or they just want to do a better job for us.” —VP

“There are certain reporting functionalities that we would like to be different. Some provider-facing things don’t work very well. We have a lot of issues with those things, and we often have to escalate those issues. We understand that Zelis Healthcare doesn’t want to put resources into making the provider-facing things better because of a conflict of interest. We are paying for the product, but it is not super high quality. At the end of the day, the system is causing friction with the providers that we contract with, and that is making things really difficult.” —Manager

Limited Data Vendors

MultiPlan

“There is more room for accuracy in the product, but the solution is fairly good and should be recommended for payment integrity.” —Director

“We would like to see more stability in our human contact as far as resources go. It seems like we often get turnover on the contact side of things.” —VP

About This Report

Each year, KLAS interviews thousands of healthcare professionals about the IT solutions and services their organizations use. For this report, interviews were conducted over the last 12 months using KLAS’ standard quantitative evaluation for healthcare software, which is composed of 16 numeric ratings questions and 4 yes/no questions, all weighted equally. Combined, the ratings for these questions make up the overall performance score, which is measured on a 100-point scale. The questions are organized into six customer experience pillars—culture, loyalty, operations, product, relationship, and value.

Additionally, the standard evaluation included the following questions specific to the payment accuracy and integrity market:

1. What lines of business are you currently using your vendor for? In what ways does your vendor support you for payment integrity?
2. How well does your vendor facilitate accurate payments?
3. How satisfied are you with your vendor as a true partner?