Decoding Payment Integrity

Mar 10, 2023
3 min read
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“By far the greatest danger of artificial intelligence is that people conclude too early that they understand it.”

— Eliezer Yudkowsky

Claims and Payment integrity platforms usually identify claims and payment contract inaccuracies. These are identified via verifying for mismatches with policies & guidelines specified by CMS, Not-for-profit organizations, and payers. These platforms should always be up-to-date with these policies & guidelines to avoid any leakages in verification. However, more often than not, these tech platforms for this automated verification are really complex, and currently offered as “black box” solutions.


A black box is a (legacy) system where there is an absolute lack of transparency in the internal workings of a platform or a system. The issues that a black box system poses are multifaceted. The first of many issues is that there is a heavy dependence on the service provider for any changes in policy customizations, creation of health plan-specific policies, and resolution of provider queries. Further, when information is passed down through multiple business users, there is often information lost in translation, which might sometimes result in a subpar quality output, which could in turn create provider abrasions and recovery challenges. These systems also hamper the speed of innovation and the go-to-market pace by an exponential amount, which again is a result of delayed vendor release cycles. Also, there is always a risk of leakages when it comes to Intellectual Property, or data security, where payers find themselves reluctant to share use cases and scenarios that are potentially path-breaking, only because they feel that data of paramount importance might end up in the wrong hands, or be misused otherwise. 


The existing legacy solutions in the market offer a contingency-based business model that financially motivates a majority of them to continue sticking to the status quo. 


There is also always a risk of slower release cycles, due to siloed workflows, and a general lack of integration between various stakeholders in the claims process. Further, inflexibility in claims administration processes often leads to a massive administrative waste. Altogether, the industry is currently devoid of an “all-in-one” solution that caters to claims and payment integrity, which needs to be fixed in order to avoid revenue leakages.


How can one fix this? 

It’s quite simple, really. There needs to be a transition made by payers from using black box systems to a platform that empowers domain experts to ideate, create, validate, test, and implement rules and new concepts on the fly. In short, there needs to be a single source of truth that will serve as both a sole workbench, and a collaborative workspace between various teams in an organization to work on, without duplicating any efforts or too much back-and-forth, thus increasing speed-to-innovation, and faster release cycles. 


This approach will not just help enable true cross-collaboration, but also ensure a smooth transition into futuristic and progressive tech, opening up a whole world of new savings opportunities. 

At CoverSelf, we have built a next-gen, cloud-native Payment Integrity platform that is open, collaborative, easy to use, and a first-of-its-kind, self-serviceable platform. The platform comes with auto-updated pre-built code sets and industry policies. Want to know more? Read about our solutions today!